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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 7 Zy <br />To: San Joaquin County <br />Department of Public Works <br />PAF <br />(Applicant Name) <br />� 13 fo ►`�,� � <br />} pp (Halling s),,��^^77�� <br />si7.L01A Jam' <br />(City, State, Zip Code) <br />x!/c -3/<, • f 7c,,-, 7 <br />( a Code-TalaphoJ1na Ngmyer)�- <br />1V <br />(Email Address) <br />plans may be <br />JOB a <br />OFFICE USE ONLY <br />730052 REF 0 <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />CRa <br />TO9/1/292T-DRNEWAYS: <br />Baker Rd. ' <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />QUAD <br />Pole Replacement ' <br />c¢nnnnr <br />Special Conditions <br />&1J ✓ N <br />�o <br />E 5 X o•9 Vic. <br />The underspned hereby applies for pe isspn W <br />to excavatg2oogsct and/or otherwise encroach oP County Highway htof•Way on <br />the si of �l ✓ �� lj approximately • i fee4 I /. ) <br />of by performing the following work (description of work): <br />G �'OXlc. 0 W lfye-.hj., <br />3c3�-1-71 <br />Work w 11 commence on or after -t - fa approx matey days. <br />I, the undersigned, certify that I am the spective property, or am qualified to represent the owner and agree to do the <br />wrod described above in accoa regulations of San Joaquin County and subject to I npect on and approval. <br />N _ <br />Slgnatu 91 - Titk Date <br />