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6 <br /> APPLICATION FOR ENCROACE74ENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE VSE ONLY <br /> TO: San Joaquin County JOBDepartment of Public WorksAPN REF # <br /> / (� ( # <br /> CIO�!h g2.L l � VALIDDA �. <br /> Z ? O 7 s- <br /> (Applicant Nam) STREET DRIVSNAYBt <br /> t <br /> El h r R' 9 <br /> ARBA UAD <br /> _. TYPE �'— <br /> �/ (Nailing Address) FORMS <br /> � UGC. lF 1 OA —1 5 7- I D NOTE <br /> (City, State, Zip Code) <br /> 4 3 y' <br /> (Area Code - Telephone Number) <br /> S <br /> ketchmay be submitted) <br /> tt <br /> t�t-vt E �.Ot �N L- -S iX7 (,-3- <br /> aTheThe <br /> undersigned hereby applies for permission to excavate; const-�xct and/or <br /> otherwise a croach�onCounty Highway Right-of-Wa o the (,� <br /> side of <br /> of — approximately feet/mile <br /> following work (de cription of w by Performing the <br /> � � <br /> r e s rlewl.N ✓�?o a-� rJo S <br /> Work will commence on or about <br /> days. for approximately <br /> I <br /> I, the undersigned certify 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 /> n3ignature - Title <br /> Dat• <br /> "IAS7112 Gs'•P393OWL !6"00) <br />