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Ric=r\j . I <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# - 300502_ REF# <br /> Departmenj of Public Works APN <br /> CR# <br /> r EXP.DATE <br /> VALID 9 r r TO /i DRIVEWAYS: <br /> v4pplicant Name) STREET <br /> ell <br /> AREA LASE QUAD <br /> G.. ! TYPE % ;y <br /> (Mallin ddress) l FORMS — � �— <br /> w <br /> NOTES <br /> (City,State,Zip Code) <br /> 155c0 3 <br /> (Area Code-Telephone Number) <br /> VSkelchedplans may be submitted) <br /> O 054r 12 `5 <br /> 6)451 <br /> The and rsigned hereby applies for ermission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the`_side of <br /> of 0f300 �X>, —�DG�E �D. approximately A? i <br /> e MESS' <br /> by performing the following work fdescription of work): <br /> Work will commence on or about <br /> for approximately days. <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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ig �tureofApplicant-Title <br /> Date <br /> E: WKIMASTER PSIENCROACHMENT PERMIT APPLICATION DOC (01m) <br />