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ASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />� y a� Ltn.Cq,s rd <br />(Mailing Address) <br />Lo S1aka <br />(City, State, Zip Code) <br />coq, 3a�-'l'777 <br />(Area Code- Tele hone Number) <br />able ohS r01C'i Arm��Ypoi1 �oYh <br />(Email Address) <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE _ <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />e undersigned hereby applies for p rmission to excavatg, construct and/or otherwise encroach on County Highway Right -of --Way on <br />�edfh sitleof/r+i/e �1 approximately_ Co©O/mile �ysf <br />`!9 E s ro�r�b e .p®/ by performing the following work (description of work): <br />z <br />'k will commence on or after for approximately da s <br />Y <br />e undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br />< des ribed above in accordance with the_rulesLand regulations of San Joaquin County and subject to inspection and approval. <br />�i�rl�► J C 1Of <br />Signature of Applicant -Title Date <br />;a TUAPI Ti 7NCR CHMKNi PeatjjT PPu�n01,6x(08We <br />e undersigned hereby applies for p rmission to excavatg, construct and/or otherwise encroach on County Highway Right -of --Way on <br />�edfh sitleof/r+i/e �1 approximately_ Co©O/mile �ysf <br />`!9 E s ro�r�b e .p®/ by performing the following work (description of work): <br />z <br />'k will commence on or after for approximately da s <br />Y <br />e undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br />< des ribed above in accordance with the_rulesLand regulations of San Joaquin County and subject to inspection and approval. <br />�i�rl�► J C 1Of <br />Signature of Applicant -Title Date <br />;a TUAPI Ti 7NCR CHMKNi PeatjjT PPu�n01,6x(08We <br />