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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE NT' OFFICE USE ONLY <br /> Date JOB# REF# <br /> ��� CR# <br /> To: San Joaquin County APN /� <br /> Department of public Works EXP.DATE TO / DRIVEWAYS: <br /> _ ~ VALID /o t <br /> Ck STREET H �� D• <br /> �f(Aapplicant Name) AREA QUAD , <br /> �/ <br /> • �J L' G n [�[7 TYPE <br /> FORMS <br /> (Mailing Address) NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) ( - 1_ t��� ��► c��t'• <br /> ACU( lel Gt r6(`c- t .� <br /> hereby applies for permission to excavate,construct andapproximately <br /> or otherwiseolencroach on County HIghwa fee Right-of-Way n <br /> The undersignedY t pp -- <br /> the [n�z�-1— side of by performing the following work scription of work); <br /> of <br /> days, <br /> for approximately <br /> nt the owner and agree to do Work will commence an or aboutth <br /> certify that I am the owner of the respective prop f Sanrty rJ Joaquin ICo my anam quaified to d subject to inspection ton and app ovale <br /> ese <br /> 1,the undersigned, <br /> work descr' ove in accordance with the rules and regulations o <br /> t� S <br /> Date <br /> gnature o plic t-Title <br /> E'.1PU&BY WW"TER-MENC0.0AC11 NT <br /> 1T APPIACAT70N.000 MR') <br /> z•d b2268976:01 <br /> bS6b6296026 :W0aA dot':S0 TT02_S2-1D0 <br />