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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# 73 �oZ'/0 <br /> APN REF# <br /> I✓ r' CR# <br /> � -- �. EXP.DATE ..- <br /> (Applicant Name) VALID <br /> STREET t".'.,0 s <br /> AREA f1Zp DRIVEWAYS: <br /> 1�Y99 LtJ. �1�nac>7q /,�,a <br /> ` c } QUAD <br /> (Mailing Address) TYPE Tim _ <br /> _ FORMS <br /> �' �f�r3? NOTES 'z <br /> ! . <br /> j (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct and/ <br /> the a;� _side of 1— j <br /> of ,�,�,� ��, �y or otherwise encroach on County Hig=ile <br /> ight-of-Way on <br /> approximately �} f ; �;�`" <br /> r by performing the following work(description of work): <br /> - '� <br /> 14/1 <br /> / _ 1 <br /> c <br /> tpN <br /> Work will commence on or about <, <br /> I, the undersigned, certify that I am the owner of the respective grope or for approximately <br /> work described above ti accordance with the rules and regulations of San Jo J J days. <br /> m' m qualified to represent the owner and agree to do the <br /> Joaquin County and subject to inspection and approval. <br /> Signature of Applicant <br /> p icant Title <br /> F'U}3V WKIMASTER PSIENCROACHMENi PERMIT q C <br /> PPLICATION DOC(0148) Date <br />