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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: P5— <br /> Date <br /> _Date p , ez I2, Zit- 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB# i I 000.r,7 REF# <br /> Department of Public Works APNI - _ CR# <br /> EXP.DAT114 <br /> E <br /> •�(a Eftve6 VALID 12 i TO ( DRIVEWAYS: <br /> (Applicant Name) STREET } �4,4 Ave <br /> GA lel 7t-l�_I AREA sfi�(�'r�N QUAD <br /> IV • WC�j(' TYPETr^enC-h <br /> (Mailing Address) FORMS of <br /> ���-1� NOTES <br /> (City,State,Zip Code) <br /> LfD(-- L�04:f5' C.d( <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 4; <br /> n t7, <br /> Z <br /> ci ww <br /> The u009��.— <br /> rsigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highpeec�ile <br /> ight-of-Way on <br /> thesideof��fl Vq�1 A V approximately (50 <br /> ofby performing the following work( ription of work): <br /> Work will commence on or about 14!:� for approximately ILf- DA44 S days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Si nature of Applicant-Title Date <br /> M.ICENTRALSERVICESCLERICALIPUMV.WKV.IASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br /> L___ <br />