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R"ECEIVED <br /> ,iUN 0 5 <br /> FRESNO APPLICATION FOR ENCROACHMENT PERMIT <br /> OMD/DPD <br /> PLEASE PRINT: <br /> Date _ �; 22� 12- OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / <br /> - VALID 3 0 3 DRIVEWAYS: <br /> Applicant Name) STREET <br /> _ AREA IkAb4q,�D p _ QUAD J-4 - <br /> 1 ��-- TYPE POLE t20LACEn+IC <br /> (Mailing Address) FORMS SSS <br /> NOTES <br /> (CVy,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hig ay Right-of-Way on <br /> the S side of_ 1 —approximately . 1`tr e Wile 0 <br /> of by performing the following work(description of work): <br /> Work will commence on or about 3 Zot for approximately days. <br /> 1,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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> I2z(I-Z <br /> Sig eofplicant-Title ate <br /> ENO.sV.Wlog&MRPS%ENCROACMENTPERUTAPPLICATION=(01M) <br />