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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date Ct " 3 �S� OFFICE USE ONLY <br /> To: San Joaquin County JOB #_71607f- �_ REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 1O•i� (p <br /> UC F 1 s ELL Q G A A'T i T VALID 0- lb TO 0•tb•l0 DRIVEWAYS: <br /> (Applicant Name) STREET M -G <br /> I-So o E. r T M i L E- Q,L) AREA � W QDAD <br /> TYPE 'nls\y r_-W U'L <br /> (Mailing Address) FORMS <br /> CA, ri' 21L) NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Cell 141b4 <br /> Sketch (Detailed plag may be submitted) <br /> PL 1i J C '-:317- Cl D)QALO i L!7- <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County highway Right-of-Way on the b 1� side f <br /> N T a.r approximately ezoe <br /> e <br /> of --- - — by performing the <br /> following work (description of work) : <br /> NQGL0 E 0 PAk ICtTO 2L C,-' i ! G(zL <br /> .Z l21�P�iJLAC� <br /> ,4ork will commence on or about '�L_o i Q for approximately <br /> t .- 2 days. <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 apprcval. <br /> Signature 4f Applicant - Tithe Date <br />