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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '�"Z—, ! OFFICE USE ONLY <br /> To: San Joaquin County JOB# _Ejeev71-17 REF <br /> Department of 70 <br /> Public Works APN o CR# — <br /> EXP. DATE ! ! <br /> VALID t a 0 L r �o DRIVEWAYS: <br /> (ApplicantIN me) ! STREET J ! <br /> ��• � AREA QUAD <br /> TYPE 2)- fI�ES IQ ' <br /> (Mailing Address) FORMS <br /> I NOTES <br /> (City, State, Zip Code) i <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> r <br /> +CD facet <br /> 7471 t3z, <br /> he u dersigned hereby applies for permissionto excavate, construct and/pr otherf�ise encroach on County f-!gh r Right Vlay on . <br /> he side of approximately UQ <br /> )f , „ by performing the following work(description of work): <br /> Vork will commence on or a�-out for approximately 1 days. <br /> the undersigned, certify that I am to ohne o'the respective property, or am qualified to represent the owner and agree`.c do the <br /> fork described above in accordance ,vitt the ruies and regulaticns of San Joaquin County and sub;ect to inspect cn and approval <br /> Signature of Applicant-Title Date <br /> 'FORMSa TEMPLUTESS,GP..0PCN6F_1,T PERWT APaUCPT N11C1Q&M <br />