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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- nn <br /> Date D , IV OFFICE USE ONLY <br /> To. San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE M-5 i <br /> �-rqa low <br /> be IM QaCOAVALID €`� T II 5i > DRIVEWAYS: <br /> (Apps nt Name) s STREET �N n1ER- <br /> AREA QUAD <br /> Qac 01 TYPE cte, <br /> I _ (Mailing Address) q FORMS <br /> �Gt fT �b�1� I S�63 <br /> _ NOTES <br /> (City, State, Zip Code) <br /> 9_V&- 91C_4_ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> + �----_ foo' I <br /> The undersigned hereby applies for perrnissiol�,to excavate, construct and/or otherwise encroach on County Hig Right-of-Wa on <br /> the flm side of }'fix(.., f�ocl approximately 5� fee mile Wp <br /> of zn � _ by pe orming the following work scriptio of work): <br /> Work will commence on or about for approximately days. <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 /> leo <br /> Signature of Applicant-Title Date <br /> Fti'cA-:vw:.n..+::'eRPaE:CF.:4ryl,ncrvi DG4++T n�oi lCyr,Oh. Cf. , .i , <br />