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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7)) REF# <br /> Department of Public Works APN CR# <br /> `,� EXP.DATE ,?�(— <br /> C lL 1 T("���I A Y V I Q� (� I C�,C VALID •t�TO DRIVEWAYS: <br /> (Applicant dame) STREET <br /> AREA1 F)9 E <br /> '- ST TYPE .� UAD _ <br /> t <br /> (Mailing Address) FORMS <br /> NOTES <br /> IST-0(21)L TO N <br /> (City,State,Zip Code) <br /> ao�1 �t t� -�� t <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County HigNfeeymile <br /> ight of Way on <br /> the -�- side of • J approximately 1 cNO- <br /> of ,by performing the following work(description of work): <br /> a L Sonoma. 4. <br /> E r <br /> 2'x y' e c.t a- <br /> Work will commence on or about 1 foapproximately (QO days. <br /> I,the undersigned,certify that I am the owner of the respective pr pe ,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 /> Signature of Applicant-Title I Dat <br /> Fk'cEMRAL.582VICE5mmcAL1Pu&SV.mAAsTERpsecROACHA7EMTPFAMRAPPLicAnoNDOC(U9m) <br /> 1 . <br />