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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> 1 b(� ) OFFICE USE ONLY <br /> r, — / <br /> To: San Joaquin County JOB 1 REB ## <br /> Department of Public Works APN CR' # <br /> Exp. DATE �'/�-� <br /> w(,l( I ei d VALID- ' TO -/8~2P_ DRIV8WAY8 <br /> �` ��� ��'� <br /> (App ioant Na�. STREET "Ve <br /> I� � TYP9 AREA /�� QUAD <br /> - <br /> W04d Q •4!!t'i1/!!E D � I�� "' <br /> � D <br /> (Mailing A <br /> ddress) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone 27umbsr) <br /> sketch (Detailed plans maY he Submitted) j _S1 <br /> fY1o��, efa(i �r� fm� i5 �HUchP�� cc <br /> . <br /> U <br /> t <br /> tv <br /> c, Se,(SMk ORWoo.o <br /> (100o � VIC <br /> mii C <br /> �Ac <br /> The undersigned hereby applie3 for permission tO .eXaavate, coF18t'r��^r, grid/or <br /> Right-of-Way ori the _ sidgof <br /> otherw'ee encroach. on County Oploximately <br /> Y esti/mile <br /> 1 <br /> b '"perform g,.the <br /> of , •, <br /> folloTfling work (descrip ion , f work) <br /> � � a <br /> FAD U/A <br /> Work will commence on or about <br /> v <br /> ,� V 4- for approximately <br /> 1, 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 /> Signature of Applic nt - Title <br /> Date <br /> mA9Tx)i.PS\rar&C=L (0001 <br /> 1� <br /> TO/TO 39dd Si Nd3d OOPS VZE689060Z Eb:LT 800Z/91/10 <br />