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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />, -ADate 1 1 <br />To: San Joaquin County <br />Department of Public Works <br />ti <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />I �(C eleph one Numbe, , <br />Ef (Email Address) <br />Sketch (Detailed plans may be submitted) <br />�w i� 1 <br />The unde s' ned hereby applies or oermission toe> <br />the side of <br />of fyAAL <br />JOS # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMSs.�AJ,_91il, <br />NOTES'GaN1�ri1D <br />OFFICE USE ONLY <br />/D REF # <br />CR # <br />20 <br />f 0 or/ DRIVEWAYS: <br />G 110z"w . <br />a¢Gy QUAD <br />_1_49 "le -4 6-f (&6e.If <br />:4 +2U_V�I <br />and/or otherwise encroach on County High Right -of -Way on <br />approximately u} ee mile <br />by performing the following work escription of work): <br />I011� Rice , wwz J%Dt4La <br />Work will commence on or after 0p for approximately 00 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 />-RA01W -i _013! 1- -- <br />Signature of Applica - Tide � e <br />Y*ORW 8TEAPIAfESEK909HWNfK WTAMJ0kT ONO1 *W: <br />