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C <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> J <br /> Date /✓ <br /> 9 OFFICE Qsa ONLY <br /> To: San Joaquin County JOB # <br /> Department of Public Works APN REF # <br /> e-1)L r� EXP; DATE CR # <br /> VALID 9iS � 411 '-'-" <br /> (Applicant Name) STREET TO J DRIVZWAYBI <br /> AREA LSU/ <br /> TYPE aGE ,� # ------ <br /> (mailing <br /> g� Addreee) FORMS k1 _Z ------ <br /> NOTE <br /> (City, State, Zip Code) <br /> ` 75e-- '��q f-Y. <br /> (Area Code - Telephone <br /> Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for <br /> eR'ightion to of-Wayeonatheei construct and/or <br /> otherwise encroach on County Highway <br /> ... side of <br /> of � � � �n �r8ximately ' t feemile <br /> / Jai �fVC-- <br /> following work (description of work) by performing the <br /> Work will commence on or about <br /> yQ ��� T /S t^ '•�?fi i i'. <br /> days. for approximately <br /> �f���� - <br /> I, the undersi fined certifaUE TCi �tiJ l�iLpC�SS /Snr 'tk%c' <br /> y 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 in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Silnate o Applic - Title <br /> P <br /> Date <br /> Ps 3Hs <br />