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APPLICATION FOR ENCROACHMENT PERMIT • ' <br />�LPASC PRINT: <br />Date '' ic) -a`dL- <br />To: San Joaquin Gounty <br />DepartmQnt of Public <br />� Works <br />CfltJ�OkQl A VV n i EF.6ri b)@,E <br />`(Applicant Name) <br />• (Mailing ajdress) <br />Ict Q1\/ C44 of, <br />(C43 State$ Zip Coda) <br />ORq ("'y �' s I 1 <br />(Area Code! Telephone Number) <br />3kefch(Detailedplansmaybesi?bmitfed) <br />Set cxtk--A-,actieA <br />Tho undetslgnedherebyappllesforpenriissionkrexcavat9,consfructandlorothetwiseencroach,onGoun[yiligh RtghFof'Wayon . <br />the 1 2( ,sideofS Tr�X IUP approximately: e de W I I <br />of P�.cShlntl��q . by pedormtng thefollowing work ( esdaption of wado: <br />Wodcwl[Icommenceonorabout - forappmximately days.. <br />I, the undem(gned, certifythatl amthe ownerof the respective property, oramqualihed to represenfthe ownerand agreato do the- <br />workdescribed above in accordance with the rules and regulations of San Joaquin County and subject to Inspection and approval. <br />r) <br />. SignaturedAppltcant4TIP ' • ' Date <br />P10ENW1BEFryCE61CIHECFI4'Hh4llWttYM91EYPSPIkR0AEH4BRPF1U4fA•°PIIaAlbil000 @91UJ _ 1 <br />OFFICE USE ONLY <br />J0B#%x'77 <br />REF# <br />APN <br />_ CR# <br />EXP. DATE <br />2 io <br />VALID <br />7! ?S" 19 D' zJ 112,0. <br />DRIVEWAYS:' <br />SIREN <br />rx &Do Am <br />AREA <br />�e J QUAD GC- <br />I <br />t <br />TYPE <br />FORMS <br />N.tJe V7 4ck <br />amu=' A&ACI <br />NOTESSebe. <br />A CeeT13� <br />rT1tk%x <br />Tho undetslgnedherebyappllesforpenriissionkrexcavat9,consfructandlorothetwiseencroach,onGoun[yiligh RtghFof'Wayon . <br />the 1 2( ,sideofS Tr�X IUP approximately: e de W I I <br />of P�.cShlntl��q . by pedormtng thefollowing work ( esdaption of wado: <br />Wodcwl[Icommenceonorabout - forappmximately days.. <br />I, the undem(gned, certifythatl amthe ownerof the respective property, oramqualihed to represenfthe ownerand agreato do the- <br />workdescribed above in accordance with the rules and regulations of San Joaquin County and subject to Inspection and approval. <br />r) <br />. SignaturedAppltcant4TIP ' • ' Date <br />P10ENW1BEFryCE61CIHECFI4'Hh4llWttYM91EYPSPIkR0AEH4BRPF1U4fA•°PIIaAlbil000 @91UJ _ 1 <br />