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s <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / (� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB #_7 ?9 <br /> Department of Public Works APN REF # <br /> EXP. DATE <br /> VALID TO S •O <br /> (Applicant Name) DRIVEWAYS: <br /> STREET AAeaj/�Qp Q� <br /> 1 l !J 604-1- AR EA 2Z)ej4 _ SQUAD _1!55 _ <br /> TYPE I <br /> (Mailing Address) FORMS <br /> GL v�-) 6 _)"�Y—/ NOTE <br /> (City, State, Zip Code) <br /> 1(4 11 <br /> (Area Code - Telephone Number) <br /> sketch (Detailed plans may be submitted) <br /> = � 1 4� <br /> The undersigned hereby applies for permission <br /> otherwis to excavate; consxruct and/or <br /> encroach on ounty highway to <br /> on , e T <br /> approximately leG� � s '.de o <br /> of fee /mile <br /> follo�sring work (Jesc iption of ork) : , �. Y perfor incr. the <br /> Worku Cis GJ N <br /> i,ll commence on or about /- /-0)�9 <br /> Ia10 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 /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> 41k <br /> Signature of pplicant - Ti le &) �� v <br /> Date <br /> MA.^::'SR.FS'FERS=L I6/C0� <br />