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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> ./f r•�� OFFICE USE ONLY <br /> Date W <br /> ���J REF <br /> JOB # # <br /> To: San Joaquin County JOB _ CR 4- <br /> Department of Public Works <br /> APN <br /> EXP. DAT <br /> VALID O /2 / DRIVEWAYS: <br /> (Applicant Name) STREET4 �►,arl ven' <br /> AREA QUAD' !'- -r-��— <br /> TYPE <br /> (Mailing Address) FORMS <br /> �. NOTE <br /> (City, State, Zip Code) <br /> pul <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) i^-��Fr�L "0rCIOL PCqUJ <br /> SHALL 8E R5 <br /> Cu 446X.:�r P(44.-M t9 <br /> P0 `J t <br /> N 31 <br /> r E fM <br /> o v <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ghway Right-of-%ay on the �A].�"1 <br /> s.de of <br /> otherwis encroach on County Hi <br /> approximatel feet/mile <br /> G, by performing the <br /> of ` <br /> followin work (descriptio of work <br /> for approximately <br /> Work will commence on or about <br /> I C)CO 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 /> Date <br /> JSiature of Applidant - TitleFEESCHDL WOO) PGM <br /> JOB M)CESSM DESK- BLD 1 <br /> I�• CA 9M4 <br />