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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> I <br /> Date / r(-; OFFICE USE ONLY T <br /> Tc: San Joaquin County JOB# 't3ooS�- 5 REF# <br /> Department of Public Works APN CR# <br /> �) EXP.DATE <br /> (Applicant Name) VALID TO DRIVEWAYS: <br /> O �� ��STREET 5� <br /> AREA <br /> D QUAD �---- <br /> TYPE ,:-/nab 0ak lc ikc i k <br /> (Mailing Address) FORMS - - <br /> { NOTES <br /> (City,State,Zip Code) — - --—� <br /> Area Code- Telephone Number) -- - -- <br /> ry <br /> • ` -'x'14.e.i -�.�y..+:1i` i �~ ,__ - _-----_-- <br /> Sketch(Detailed plans may be submitted) --- <br /> Y L,! t . : C <br /> -� 3 c-�, <br /> II� <br /> The undersigned oereby applies for permission to �cavate,construct and/or otherwise encroach on County Hi Right of-Way on <br /> the 'side of �,;.�1 l �, t <br /> of + f , approximately fee mile <br /> by performing the following work scription of work): <br /> -- 54 + ;_�u,l e <br /> -----Work ------ <br /> will commence on or about- ?� L 1 - - <br /> . '% for approximately_ <br /> J - <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 /> wor�dn�ie bove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ly lf, <br /> Z -/Sigrtkture of Applica -Title Date <br /> WUB:V.,. ,r,. EN I H[H.WI AHHL CA I q,pq <br />