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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ uSt 2r , 2=0 OFFICE USE ONLY -_______ <br /> To. San Joaquin County JOB# REF# <br /> Department of Pubic Works APN CR# <br /> C 1C5tICC' ©kd1S ( EXP•DATE O- /- o <br /> l �� ���} VALID 9-/!-c _ T{} f -/ DRIVEWAYS: <br /> (�Name} STREET Ger `! ! <br /> AREA C t QUAD <br /> ? '7J �ct0�� Dave TYPE ,---; <br /> (Marinn9 Address} FORMS <br /> „__---- <br /> _� NOTES ; <br /> (City.State,zip Code) <br /> (9(6) 9IB3- s� <br /> (Area Code-Telephone Number)- <br /> Sketch <br /> umber)-Sketch(Detailed plans ma}r be submitted) <br /> i <br /> t car �NrC4 c (- CCA-)- -o l <br /> i <br /> t <br /> thee undersigned <br /> hereby applies for permission to excavate,constW arld/Or otherwise encrOarh on County Hi <br /> _,_.side of � ec.#' tY � Right-of--Way on <br /> of approximates LA a 0 mile SQA h <br /> 1 o vv+aca { by pe*m*V the following work ption of : <br /> Work will commence on or about Q. <br /> ' for matety �' days <br /> I,the undersigned,certify that I am the owner of the respective property,or am Quatilred represent the owner and <br /> wort[described above in accordance oath the rules and regulations ofi San J agree to do the <br /> oaquin Amy and sufoet to inspection and approval, <br /> Signature icarit-Tine <br /> Die <br />