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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRI(. <br />0 <br />To San Joaqun County <br />Departrrerd of Public Works <br />(AP*Mft Nam) <br />s <br />(Mailing Address) <br />(City, State. Zip Code) <br />(Area Code - Td{ephone Number) <br />(Emai3 Address) <br />JOB # <br />OFFICE USE ONLY <br />730052 REF <br />APN <br />CR 9 <br />EJB. DATE <br />VALD <br />STREET <br />5/1/2024 TO 11/1/2024 DRIVEWAYS <br />Jack Tone Rd <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />Q1AD <br />Aerial Work <br />SSNVW <br />Special Conditions <br />%st h (Detailed plats may be submitted) <br />�Ce- <br />-- iT E P <br />fx <br />The u hereby applies for pemtww b excavate, ocnshrrct ardfor odterwise encroach on County Highym ay %Otof-Way an <br />the � side of wv aPP {�tNY ffeeeY�ntile,, r <br />d^re..✓T.' iY �C .`y Nthe NO(ICtwsc�iW�n�1� <br />/,� <br />Work will comrttmm on or ager - - 7-14 for apProxmateN r.: tr daM <br />I, the undersigned, certify that I am ttte respecM property, or am quallied to represent the owner and agree to do the <br />work described above in777� <br />nd regutagmt� ot San JoagLm Out and sb)ed to and approval, <br />S wAtumd • Toile Dmb <br />