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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:. <br /> Date OBIFICE vsE ONLY <br /> To, San Joaquin County SOB_#�(,J �. ��'_�RE>~ # <br /> Department of Public Works APN CIR: # <br /> EXP. DA.T'E r 7 t <br /> VALID " [ TO ot DRIVEWAYS: <br /> (A-pplicant Name) STREET %hI * <br /> �lVC,2 P>re1� P�4c-- AREa QUA x <br /> TYKE <br /> A Q <br /> (mailing Address) FORMS � <br /> NOTE <br /> (City,, State, zip 'Cade) <br /> (urea Code Telephone Nu-ber) <br /> FM <br /> 4-1 Zo <br /> Sketch (Detailed pians may be submitted) <br /> The undersigned hereby applies 'for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the -t;007—k side of <br /> I�RP'M-r L LiV IE jFoA0 aroximately I Z 3? --feat mzle• <br /> of di �` _}7gAC5-TAL e-&6a M i:u , by 'performing the <br /> following work (description of work) <br /> Work will commence on or about ��t1f 2 ��2(� for approximately <br /> days . <br /> 1, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above ±r_ <br /> accordance with the rules, regulationa of San Joaquin_ County and subject to <br /> inspection and approval . <br /> za,;-Z� <br /> 6ignature of Apply ant _ Title Date <br /> :fix i'T::A..PS\G'EEB CHDL (6/UOS <br /> ZO/ZO 39ad slzl,•JdGd 03fS <br /> bZE689b6az LB �bL �GJ�G';LZ/?g <br />