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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J Gv�IJ�GI r Z— OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 1< <br /> I EXP. DATE 3 2 70)2. <br /> ( e`` VICA h KI VALID Tb S12-4126)7- DRIVEWAYS: <br /> (Ap icant ame) STREET D 1p&,5D <br /> 2 AREA ��p QUAD ,tel„/ <br /> J?, D • B 0)( J� ��' TYPE If pC -C S <br /> (Mailing Address) FORMS y" <br /> NOTES <br /> o C 9 oe <br /> (City, tate,Zip Code) z� <br /> �2 66 -- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> -r <br /> r <br /> V <br /> r1A)15 <br /> The undersigne hereby applie�perrmi s on fo xcaiva ie,coDstruct Id/or otherwise encroach on ount ighway Ri ht-of-Way o <br /> the S si a of approximately bM-4 fe mi e <br /> ofZ2 by performing the following work(description of work <br /> ork wj I commence on or about. t j, — / ' 04wN for approxim ely � days. <br /> payt, <br /> I,the undersigned, ceRy that I am the owner of the respective property,or am qualified to represent the owner and agree to dle <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 2 10 <br /> f � <br /> SignrOACHMENT <br /> of Applicant-Title <br /> D1�em <br /> E.1PU8-SV.WKWASTER.PS1 PERMIT APPLICATION.000 (01108) <br />