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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date . -�- �3AW <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # �7�7 (-� <br /> Department of Public Works REF # <br /> V _ APN CR # <br /> Exp. DATE 5, <br /> oto <br /> t (Applicant Name) VALID 4 3 TO !S OCo -., <br /> STREET , '0.L Hocu», DRT AY9� <br /> G l (2t ��1 l � AREA �Acy QUAD <br /> TYPE5pucr�P <br /> (Mailing Addresg) * �_ <br /> FORMS SSL ted). ZS► . <br /> NOTE <br /> (City, Stata, Zip )do) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) ` <br /> m o D <br /> .. 2 <br /> o =v o <br /> w <br /> - cc �. •[ <br /> 0 � t-i <br /> x� �D <br /> _ �c <br /> ul <br /> The undersigned herebyor - <br /> ot erwi.se en ro�h ori County Highway eRight-Of-ay onthe <br /> rmission to excavate,- <br /> construct-and/or ' <br /> o tL.�La►L �j � s'de -of <br /> of=� approximately- <br /> following wo (description of work) : ' , by performing the <br /> A . <br /> t l ow t1.J. <br /> Work will commence on or about <br /> days. o for approximately <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 /> (A16 <br /> Signature of Applicant - Title <br /> Date' <br /> M'STBR.PS\MSL <br />