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APPLICATION FOR ENCROACHMENT PERMIT <br /> nEA3 PRINT• <br /> Date <br /> oV71CX V8S ONLY <br /> To: San Joaquin 40unty ' <br /> JOB #_� � RSF # <br /> Department of Public Works Jos <br /> EXP. DATE - -z) <br /> VALID "-c7 T _Cx DRIV$p]►YB: <br /> (11pDlicaatr 'XPains) STRSST ct <br /> 2i)� j�. 1�L! AREA �i QvAD <br /> =LL ' TYPEC c-fi&14E l�j + <br /> •----�� (ling &ddrove)) F0 � v. <br /> /17 <br /> (City, tate, zip Code.) <br /> (Area Code Telepheae Humber) <br /> Sketch (Detailed plans may be dvl=ltted) <br /> The undersigned hereby applies for permission to excavate, onstruet sad/or <br /> of encroach ty 8igh�ray Right-of-Way t e side of <br /> of approximately eet'mile <br /> fol in work ( a i of k) ; PIP the <br /> r <br /> r <br /> work will commence on or about /> <br /> days 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 /> aceo;dance with the rules, regulations of San Joaquin County and subject to <br /> inspection and appro <br /> Sign tur of Applicant -r-Titlr <br /> L�l�lN�' set <br />