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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT. <br />Date <br />To San Joaquin County <br />Department Public Works <br />i <br />(Applicant Name) <br />JUC/NS 1"Y <br />(Mallin ) <br />�� ac Co 4 <br />(City, State, Zip Code) <br />2,ori Z -4Z � S <br />(Area Code • Telephone Num r) <br />(Erndl Addrm) <br />JOB# <br />APN <br />OFFICE USE ONLY <br />730052 REF <br />CR # <br />EXP.DATE <br />VALID <br />STREET <br />-615 TO DRIVEWAYS <br />—eourtrreYf�r' <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />tuL;aWAD SE' <br />Aerial Work ' <br />bpecial L;onditions <br />Sketch (Detailed plans may be submitted) ly <br />i wt Uri �! <br />� c <br />15 <br />The undarsi hereby applies for permission to excavate, consbW and/or otherwise encroach on County Highway Right -"ay on <br />the side of C,,,, approximately 7o / eedmle -�) <br />3) it 1 by performing the following work (description of work): <br />iv ✓a0/�ir tOti, he n.., -).la <br />Work will commence on or after I for approximately days. <br />I, the undersigned, certify that I am respective property, or am qualified to represent the owner and agree to do the <br />work described above in acco with_tba4uWs and regulations of San Joaquin County and subject to inspection and approval. <br />pnature of AR • Title - - Date <br />