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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: f <br /> Date Jy��// 7ti/Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# Z3G1�J•5 a--S� REF# <br /> ~� Department of Public Works APN CR# <br /> EXP.D0 9 -7 V�� VALID A7E Toa DR S: <br /> (Applicant Name) STREET /fs OnG"i�G[► <br /> /� ff AREA AD <br /> TYPE e e <br /> (Mailing Address) FORMS <br /> NOTES <br /> D _ <br /> (City,State,Zip Coae) <br /> 760 - 2979 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 60/0 12 - -00 (��pPe/0,70IrS /'�(:: <br /> _ G(?/ scx> <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of ,by performing the followm work(description of work): <br /> /2s E Sr e- - ':!4' <br /> ti 2�ct� I" G <br /> A <br /> Work will commence on or about r,,' 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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> r <br /> Signature of Applicant-Title Date <br /> 'IDi4V�z� <br /> EWU"VWWIMEerSOCROM"MirPMWAPPMA LWC JawR <br />