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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLSASL PRINT: -fr ! 'I 1 <br /> Date 7,T__as ��o a OFFICE USE ONLY <br /> To: San Joaquin County JOB Z 717 REF # <br /> Department of Public Works <br /> CA�IFOR�11�'�1�f AT�t� S��V VALID• A w TO DRIVBiiQAYS: <br /> (Applicant Name) STREET E <br /> AREA <br /> (Mailing Address) FORMS <br /> NOTE _ .• <br /> (City, State, .Zip Code) = <br /> ao"'k- 'Ala'A-a31� <br /> (Area Code - Telephone Number)• <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otb e w se-encroach•on County-Highway Right-o€-Wa• ••os-the <br /> D�]:!�Acse_ ` approximately fee mile 6 }" <br /> of TJY/.�'T /I�r4� i' , ''Of c6 ' .,. . by performing the <br /> following work (descriptionO of w(; ;k) - _ , 0` `'n t5VI <br /> _ . . <br /> Work will commence on or'about for approximately <br /> 100�1 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 rul regulations*of San Joaquin County and subject to <br /> inspection and approvalT(� <br /> Signature of Applicant - Title Date <br /> KwnM.j?S\#M CzM (61001 <br /> i <br />