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Jan 2813 03:37p Thornton Fire District 2097942946 p.1 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date )-2f OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> It 0 Ci VALID 2 ZY3 /3 3 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA UAD ' <br /> - TYPE /!.� ✓o 'e " <br /> (Mailing Address) FORMS .i <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pians may be submitted) <br /> The undersigned hereby applies for permission to excavate,cflnstruct and/or otherwise encroach on County Highw -Right-of-Wayon <br /> ' side of•f�-"cry.. - rte ,i I'�1 rn� L—k— <br /> ee#�ii�approximately i ile <br /> of 7;A; �, _,;F i � .by performing the following work(description of work): <br /> i <br /> Work will commence on or about 2- `? - - ` 4-^ 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 des ibed ab 'n accordance with the rules and regulabo>ns of San Joaquin County and subject to inspection and approval. <br /> .13 <br /> Signature of Applicant-Title Date <br /> E:''PUR-W.'NKt4045TEF P5.:NCROAC•OIEIJT PE urAPPLICATCN.DW;01&9 <br />