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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date i„ — <br /> OFFICE USE ONLY <br /> Tz): San Joaquin County JOB #13rD'?S- <br /> 1.Department of Public Works APN REF # <br /> ti L �S AP\7T <br /> EXP. DATE <br /> VALID r O TO 2 J }U DRIVEWAYS: <br /> (Applicant Name) STREET _T1i,�t/G(� <br /> AREA f_esb J QUAD __il/G✓ <br /> TYPE -'ems GOi c�L ?SYS► ------- <br /> (Mailing Address) FORMS <br /> _ 0"G J NOTE <br /> (City, State, Zip Code) <br /> (Area Coda - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies <br /> otherwise encroach on County Hi for permission to excavate; construct and/or <br /> for <br /> Right-of-Way on the -S CAr_7"Z Cside of <br /> o���y� r1� approximately / �� �' feet/mile <br /> following work (description of work) : ° by performing the <br /> L�C�'- '; ",��„ <br /> Work will commence on or about <br /> days. fcr approximately <br /> 1, the undersigned certify that I am the owner of the respective property, <br /> Tlalified to represent tine owner and agree r-o do t . p P e : am <br /> acccr3ance with the rules, rQ g re work described abc•re in <br /> _gulaticns cf San Joaquin County and suc_j to <br /> inspection and approva� <br /> 04. <br /> Signature of Applicant - Title <br /> Date <br />