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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- <br /> t <br /> Date OFFICE USE ONLY <br /> To: San Joaqu n County JOB# REF# <br /> Department of Public Works APN _ GR# <br /> j�� 1� EXP.DATE <br /> -► y1 � e-st eryx /O/J VALID T i DRIVEWAYS: <br /> ](� I;Ap cant Name) STREET " <br /> AREA ,QC QUAD ' <br /> TYPErpt a re— <br /> _ <br /> (Mailing Addres95-,;S6-3 <br /> s)' Z-7 <br /> FORMS _ G <br /> Pt + 5 l 5�6-3 NOTES <br /> (City,State,Zip Code) <br /> aN 1� b <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> &nta lQoJ <br /> I <br /> The undersigned hereby applie for permis ion to excavate,construct and/or otherwise encroach on County Highway ht-of ay on <br /> theEa nd t.J�Side of '� � approximately Q.� rrmVp— fee ii A�, <br /> of 'moi�, by performing the following work(descnption of work): <br /> Work will commence on or about i for approximately _days. <br /> I,the undersigned,c�3Iify 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 /> 7h <br /> Signature of Applicant-Title Date <br /> V�uB4VwWM OERP9,EtttrtMCSa:_NP(YWT-APPUCA-,*N.DOC(01M) <br /> EO 17R S'a1Hq `)(TT ta7fiC'7C.QC1a7 7T'QT TTn7 1TT I.n <br />