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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> --5X7f-'3 REF# <br /> OFFICE USE ONLY <br /> B <br /> Department of Public Works JO # REF# <br /> A FPN C # <br /> CR# <br /> EXP.DATE <br /> V <br /> VALID TO <br /> DRIVEWAYS: <br /> (Applicant Name) STREET STREET <br /> AREA 14 QUAD <br /> I-E 0 <br /> (Mailing Address) TYPEFORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 7 <br /> (Area Code-Telephone NUmber) <br /> Sketch (Detailed plans may be submitted) Cq <br /> 7��7 jk*e-q-'��/0' <br /> The undersigned hereby appIie�forpve"rmission to excavate, construct and/or otherwise enc <br /> the fAbR4 i�i- side of roach on County Highwa Right-of-Way on <br /> approximately L-7 mile_G46T� Ufc-TH <br /> of <br /> by performing the following work(description of work): <br /> 2-- <br /> t Te <br /> AQ-S- iT1-tiiti <br /> LL T -z- S& <br /> CAY <br /> -F -,t Ct-- (--� � <br /> (�--c� L>1" <br /> Work will commence on or about 2-C-- - i i }�C (--) t--("?, —(' E- Dc LUQ <br /> for approximately_7'- -K -' <br /> days. <br /> 1,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 /> Signature of Appljeant,L TW <br /> Date <br /> E TUB-SV VWMASTER PbENGROACHMENT PERMI C <br /> 1(7�PPLICATIONT <br />