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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Dale to —0-70 <br />To San Joaquin County <br />Department of Public Works <br />;1 <br />(Applicant <br />(Applicant Name) <br />(Mailing Add s) <br />.�.4x liYd 9.R4 6 <br />(C4, fib, Zip Cods) <br />moi z *712— c�—cp z? <br />(Arse Code - Telephone Number) <br />—���vt' ep c,P <br />l(Email ss) <br />JOB M <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMAS <br />NOTES <br />OFFICE USE ONLY <br />730052-6 REF <br />CR M <br />1/1/2021 <br />7/1/2020 TO 1/1/2021 DRIVEWAYS: <br />FRENCH CAMP RD. ' <br />MAN I LUAQUAD NW ' <br />POLE REPLACEMENT ' <br />SSAMN <br />SPECIAL CONDITIONS <br />Sketch (Dented plans may be submitted) <br />a Tk <br />Cc- rS' <br />The unQersgned hereby applies foype tocavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the side of Y✓tx Lc.+a r appro>;nl3ity^ol t Z 7 CSS feetlmileC, <br />Of by pedonrling the following work (description of work). <br />O <v J <br />Work will commence on or after 0-1-6 \ — ? -A 7 n for approximately days. <br />I, the undersigned, certify that I amt respective property, or em qualified to represent the owner and agree to do the <br />work described above in nce with the rules a regulations of San Joaquin County and subject to inspection and approval <br />