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APPLICATION FOR ENCROACMSENT PERMIT <br /> PLEASE PRINT• - <br /> Date __ 7�(1� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # Q rf9'3 <br /> Department of Public Works ?EF # <br /> APN CR # <br /> ` EXP. DATE 11 <br /> VALID g/SGYo TO G / p _ <br /> (Applicant Name) STREET orf/ DRIAYS*- <br /> L M AREA _ QUAD S <br /> (� ling Addreaa) TYPE —� <br /> l_ 1 FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 10L q thin <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) rn <br /> o S o` <br /> CD c <br /> The undersigned hereby applies for permission to excavate; construct ,and/or <br /> otherwise encroach on County Highway Right-of-Way on the <br /> side -of <br /> of;, aPProximately 'TT <br /> oll wing work (descript on of work) : � • by performing the <br /> � � b db ' � Tt,.:3 ♦.. tilt <br /> Work will commence on or about <br /> days. for approximately <br /> telr <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 /> S gnature of A plic t - Tit <br /> Date <br /> MxSK'SR.PS\rassa�L (6/007 - - <br />