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APPLICATION FOR ENCROACM4ENT PERMIT <br /> vLEUE PRINT: <br /> Date le'). — 19 OFFICE USE ONLY <br /> To : San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> n <br /> EXP. DATE A"!5-0 y <br /> Lt �stX X J VALID 11-/S46 TO DRIVEWAYS: <br /> (Applicant Name) STREET �i�E AJC <br /> AREASTac,KTa" QUADSVS <br /> TYPE eeAMO,e 154-V W .QE�J9le <br /> (Mai ing Address) FORMS -�� ^2 <br /> -NOTE <br /> (City, State, Zip Code) - <br /> q <br /> Ze5 S<o <br /> (Area Code - Telephon Number) . <br /> Sketch (Detailed plans may be submitted) <br /> R G —AC E, <br /> The undersigned hereby applies for permission to.excavate, const mat and <br /> otherwi e-encroach on-CoLmty Highway Right-of-Way on.the of <br /> CA"AAA approximately SO fe /mile <br /> of 57FAler by performing the <br /> following work (des ription_2L work <br /> 419 <br /> Work will commence on or about 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 /> Signature of Applicant- Tit Date <br /> MASTRR.pS\HBBS®L (6/00) <br /> i <br /> 1 <br />