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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I-tet— I -).,_ <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7.3007`-3 REF# <br /> Department of Public Works APN <br /> CR# <br /> 'AC.VEIC- 2 ELL DP,.k EXP.DATE 2 iS a <br /> VALID 2 /Z TO /z <br /> DRIVEWAYS: <br /> (Applicant Name) STREET ,� <br /> Z' F 61-1 I r1 I LE R 0 TYPE AREAQUAD /1/� <br /> (Mailing Address) FORMS <br /> S I UUC j 00 � ���-�� � NOTES <br /> (City, State, Zip Code) <br /> _f2UC\ y 9 L�- Ltl0 S I <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> P L Z/zS r <br /> The undersigned hereby applies for permission to excavate constMi <br /> MPr <br /> erwise e c ach on County Highw Right-of-Way on <br /> the . f�'T`)�i�side of 101 fi L of i t� imatelya <br /> P LACK G IZ 0 U N� Q�D UA—i G A S� DIP <br /> by performing the following work(description of work): <br /> �1- _T lei t�� h i l�J I S co- <br /> C111— 'r( :� t L Ft ? I h�t <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 /> "vork described above in accordanrth the rules and regulations of San Joaquin County pp and subject to inspection and approval. <br /> +i o/al. <br /> Signature of Applicant- itfe <br /> Date <br />