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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFfCE USE ONLY <br /> To: San Joaquin County FAPN <br /> j 0 077 REF# <br /> Department of Public Works CR# <br /> ,TE CC VALIDI(���- j TO DRIVEWAYS: <br /> (Applicant Name) STREET � n <br /> AREAX16! QUAD <br /> E 7 t-- ST TYPE <br /> (Failing ddress) FORMS <br /> S�0 NOTES <br /> L>L r o tv � `n7 <br /> (City,State,Zip Code) <br /> I; y <br /> (area Code a Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for pe mission to excavate,construct and/or otherwise encroach Coun Hi <br /> the i,U side of S�, ty y Right-of Wa on <br /> .�41 L D�,8 9rcl . approximately fee mile N r` <br /> by performing the following work( esc6ption of work): <br /> L� <br /> EryyA <br /> AA <br /> Work will commence on or about 1 I - for approxima ly <br /> l > days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualifed to rep esen he ovdner 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 Ti it <br /> Qate <br /> M:ICEWRALSERVICESICLERICAL1PU8SV.WKVAA57FR.PMCROACHAIENTPERMIT APPUCAn0KDOC(09113) <br />