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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �- 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB# IU65'2__�- REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> VALID to 2 e DRIVEWAYS: <br /> (Applicant Name) STREET ee 9Jj, <br /> {�S +� AREAy� QUAD AA�Z i�/�Rk► � 4cz TYPE LR GtAGXY " <br /> (Mailing Address) FORMS <br /> NOTES <br /> A q3-7 ZO <br /> (City,State,Zip Code) <br /> Com) X47-5Z4rn -MAA-tc Al <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) T' It -�Sy Cl 40 <br /> A-TT//�� <br /> Z C. I-W ck <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately —7Z + rnile � <br /> of �=Is, pY� � �„p�e"�, by performing the following work(description of work): <br /> POLE <br /> Work will commence on or about_ 1 -, - ( for approximatelydays. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> .�®yi;� v • J��j-'" �-..,_G�5 P`I yn�.0 � 14 2c3/G� <br /> Signature of Applicant-'Title Date <br /> E'IPUB-SV.WNIMASTER.PSIENCROACRMENTPERMlTAPPLICATION.000 (01/08) <br />