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APPLICATION FOR ENCROACHMENT PERMIT <br /> FLEM PRINT: <br /> Date 1 l /- ? <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB oc>C"I<, REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE _ �-Z Z- Z <br /> C. QCT,D ► e VALID _za&iTO _ o DRIVEWAYS: <br /> (Applicant Name) STREET C�6SS C�I(,S ; <br /> � 4 • <br /> • 0. ��x 6 / b l AREA 46 QUAD tJ W <br /> TYPE <br /> Malling Addr ) FORMS S <br /> O c .a NOTES . <br /> (City,State,Zip Code) <br /> � oq <br /> Area C�ode �Telepho�neoun�ibej <br /> Sketch(Detailed plans may be submitted) <br /> r. r <br /> t <br /> a AP10 0 =oar -09 <br /> r <br /> r <br /> s5-d e,k !� <br /> The undersIgne hereby applies for rmission tq exc vete,c nstruct and/or otherwise encroach on County Highway of-Way on <br /> the side of G c/ approximately fea <br /> Y peribrming the toilowing work(desc ption of work): <br /> Work wig commence on or about S for approximately O/1 P days. <br /> I,the u certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work d above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> SIA nature of Ap 11C ide <br /> Tif it 14�G7?t. is �e�, STe:/1 �joffT (r•-✓lost <br /> C:���s 1'4Q69) S43S . <br />