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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /,0 7/0OFFICE USE ONLY <br /> To: San Joaquin County JOB # f(0OS REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> IA- VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET X:�42> <br /> AREA QUAD AIAI <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (7,07) 3 7 y- Sig <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County Highway Right-of-Way on-the .EgST. side.'of- <br /> .4 -,)A /20e approximately /ao feetAmil Ga- 7-A/ <br /> Of t'_PA "r-r 1 by 'performing the <br /> following work (description of work) : 14,/c 71c� sT <br /> Work will commence on or about © �3© for approximately <br /> / days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Sign of Applicant - Title Date <br /> .PS\FESS®L (6/00) - - <br /> I <br /> r\ <br />