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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' 0 11- 910 ( <br /> �j OFFICE IIS8 ONLY <br /> To: San Joaquin County JOB # REF ## <br /> Department of Public Works APN CR,• # O 3 p <br /> ),, <br /> EXP. DATE <br /> an a 1 e co � Y � VALID. TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 5 C Z AREA QUAD <br /> TYPE <br /> (Mails Address) FORMS <br /> NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> (2-09 ) 62-9 - 12,S-1 Lel) 2al F7_ <br /> vv vy- <br /> Sketch, (Detailed plans may be submitted) KYNOY a V­' 1 r <br /> 1 <br /> _J <br /> The undersigned hereby applies for permission to <br /> .excavate, .conat ct and/or <br /> otherwise-encroach on County Highway Right-of=Way-on-the_ side.,of <br /> approximately feet/mile <br /> of (� lD-nA�d�✓�G-� , by 'performing the <br /> following work (description of,work) : <br /> Work will commence on or about — r -N Z' or� approximately Z � <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 - /Title <br /> � (°� Date <br /> HASTSR.PMUSC®L (6/00) l.�-/� ` c V j� <br />