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F =h1 HLIFOF'IJIN 1:19 R 'SER, 1111E FA::, 110. :209-4640195 Tul. 21 ��;_' �r _2F'Pi F' 4 <br /> APPLICATION FOR ENCROACEMENT PERMIT," <br /> ,PLEASE PRINT <br /> S <br /> Date _ a-1 ,UY 119 y 44� orrics USE OMY <br /> To: San Joaquin County TOB REF <br /> Department of Public works APN CR: # <br /> �► <br /> EXP. BATE <br /> VALID .< 0•,,,,� TO � %, DRIVLP7AY5 <br /> (Applicant Name) STAT Z::_ f <br /> ®° AREA 20 QUAD <br /> TYPE <br /> (mailing Addross) FORMS . <br /> NOTE <br /> (City. State, .Zip Code) <br /> (Area Code - Telephone Nunber). <br /> Sketch, (Detailed Plans may be submitted) <br /> The undersigned hereby,applies for pe=issiou to.excavate, construct and/or <br /> otherwise--encroach.on County•aighway. Right'-of-Way'•oa the <br /> approximately :' C c 'mx e tA(N Zc- t1 <br /> fo • T, 4. , by verfoxminS the <br /> following work (description of:work) <br /> A-`XQ2 <br /> Work will commence on ox'about for approximately <br /> 19C) days. <br /> T, the undersigned certify, that X 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 rule regulatioriks of Sam Joaquin County and ,subject to <br /> inspection and approval. <br /> Signature of Applicant Tithe Date <br />