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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEAS$ PRINT: <br /> i <br /> Date ��/ / V b OFFICE USE' ONLY <br /> To: San Joaquin County JOB # REF ## <br /> Department of Public Works APN CR ## o s o q ►2, <br /> c EXP DATE <br /> VALID 11-I5- TO DRIVS'IFAYS: <br /> (19plicant Name) STREET _1lAtV&J.S 4QETro0 S +* <br /> AREA `.SfdGkT64 QUAD y <br /> Z-7 n "."4 S•i-� TYPE -?,,I <br /> * — — <br /> (Mailing Addres®) FORMS NOTE <br /> 1:4 <br /> (Citi, State, Zip Code) 1 <br /> j <br /> gczo7,' <br /> T(Area' Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> _ I <br /> The undersigned hereby :applies for permission to .excavat.e, .cons•truct and/or - <br /> otherwise- encroach on County Highway Right-of-Way on-uh + "E <br /> VA�21O <br /> a� by 'performing t <br /> following work (description of work) : T., P /;.;_r. /0 <br /> d n..•,b•a ,.,.� .1._o {��_���e- /.,e '� IT�' <br /> Work will commence on or about _Usti 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 /> C <br /> Signature of App icaat - Title l Dais <br /> MASTSR.PS\SSSS®L (6/00) <br />