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APPLICATION FOR ENCROACHMENT PERMIT <br />PtPAS� PINT: <br />Date <br />To: San Joaquin Gounfy <br />Departm ent of Publtc woft <br />�` �rt�Pn�rR art �5E7U.I✓C <br />(ApplfcantNaito) <br />1 0a c • [.flrmve:ITrr• Ew. <br />(MaiNngAddrese) <br />(0y, state, Zip Code) <br />iaOR1 IV t,,Y �'S3I 1 <br />•• (Area Gods! Telephone Number) <br />S9gs <br />Tho undersfgned berehy applies for�pennissio�Lto excavate, cgnsfruct and(or otherwise encroach.on County Nigh• f�fghfi of -Way on . <br />the�uS�sfdeo# N �I� Tom. Pie approximately 2 fee mife,�rfc); <br />naLwot <br />, <br />VUedcwillcommencegnoraboufi -2o forapproximafely days.. <br />1, <br />bypertarmrgihefollowiggwork ciiptfothe underslgned,certffythat I anrthe owner ofthe respecttva property, Dram quali#fed tto represent the owner and agree to do ihe- <br />workdescdbedaboueinaccordancewlfhthetnlesandregu(ationsnf5andoaquinCounfyandsubJecttofnspectlonandappreval. <br />mpg <br />1ACEHIIW&@MCE51CIHtlCAIV'L48V.WiM•us1EAe MKAOACµiIt1RPFM'RP+NOA7Ni11000 NN13) <br />it-as-ac19 .. <br />• 'Dat® ' <br />OFFICE USE ONLY <br />JOB# <br />7sG1d7'% REF# <br />APN <br />CR# <br />EXP. DATE <br />Z t r Zb <br />VALID I <br />izilI TO is zoo,DRIVEWAYS: <br />STREET <br />IsOLDE&) GATE A <br />AREA <br />97heACrdcJ QUAD Ai% k t <br />TYPE <br />FORMS <br />156Ut 6 0a <br />Wkivitf/ �24Ca <br />+c.j <br />NOTES' <br />)* <br />Tho undersfgned berehy applies for�pennissio�Lto excavate, cgnsfruct and(or otherwise encroach.on County Nigh• f�fghfi of -Way on . <br />the�uS�sfdeo# N �I� Tom. Pie approximately 2 fee mife,�rfc); <br />naLwot <br />, <br />VUedcwillcommencegnoraboufi -2o forapproximafely days.. <br />1, <br />bypertarmrgihefollowiggwork ciiptfothe underslgned,certffythat I anrthe owner ofthe respecttva property, Dram quali#fed tto represent the owner and agree to do ihe- <br />workdescdbedaboueinaccordancewlfhthetnlesandregu(ationsnf5andoaquinCounfyandsubJecttofnspectlonandappreval. <br />mpg <br />1ACEHIIW&@MCE51CIHtlCAIV'L48V.WiM•us1EAe MKAOACµiIt1RPFM'RP+NOA7Ni11000 NN13) <br />it-as-ac19 .. <br />• 'Dat® ' <br />