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APPLICATION FOR ENCROACIMENT PERMIT <br /> 'PLEASE PRINT <br /> Date � 1 � _ , •. <br /> OFFIC$ U88 ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN Cy # <br /> GEXP. DATE /l.l -4eo <br /> b LAA GC �`�j`c��/�� VALID 11-! -O TO //-el DRIVEWAYS: <br /> (Applicant Name) STREET -aVzft3r �_���� 7z 't> * <br /> AREA-tQAC.,' QUAD 5� <br /> TYPE a_oRD <br /> (Mailing Address) FORMS SS�WcO <br /> CD NOTE� <br /> (City, State, Zip Code) <br /> 'ao g - (Ike <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ��ec4se sem �-ceC�e <br /> o, Tt. O's <br /> The undersigned hereby applies for permission ito .excavate, construct -and/or <br /> otherwise-encroach on County Highway Right-of-Way-oa•the <br /> side -of <br /> approximately�' feet/mile <br /> ' <br /> following work by performing the/ (description of work) : <br /> '` Oe!AAt* Q 1 <br /> y� <br /> C-6 0 c St <br /> Work will commence on or about OVA aK for a y <br /> 2 days. =-v ;\\ b o�� 5,4Q�dct� - PProximatel <br /> f d s� d�,,� • <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 /> aan T"P r <br /> Signature of Applicant - Title Dat <br /> MASTSR.FS\PSBS®L (6/00) - <br />