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I�tGR S 7 r 4 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> JOB# PVA c REF# <br /> To: San Joaquin County CR# <br /> Department of Public Works APN _-- <br /> EXP.DATE , DRIVEWAYS: <br /> C l-(t2 is C Y N C,0 VALID <br /> (Applicant Name) STREET .q`Q <br /> AREA QUAD 9�:c <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 7K3- X5"%' 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) � "1 <br /> p, <br /> }. r <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hi hway�t-of-V�aY,orn <br /> the �S side of-,V 9 �¢t��" R approximately ,�35 - fee ile--rte <br /> of tuvoh >�� K.N. ,by performing the following work(description o WO <br /> rk)' <br /> C- C <br /> gni <br /> Work will commence on or about '' - 1 for approximately <br /> days. <br /> I,thg , <br /> e undersi ned certify that I am the owner of the respective property,or am qualified to represent the owner and agree to dOo�the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection a pp <br /> �3 <br /> Date <br /> Sighature of Applicant-Title <br /> kA,CENIRALSERVICEA0.U*ULVPUS.VWKUAST-.RPMNCROACHMEHTPEMt APRIGT7CN DOC l=131 <br />