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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 C1125�/�j/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# -it 00 05 REF# <br /> Department of Public Works APN -2-4 s-140.10 145-13� 25 CR# <br /> �nnuJJve EXP.DATE Z -(S- I S <br /> rh:n=few <br /> Oro - VALID 11 -7- (5- TO _2-(s'-/S DRIVEWAYS: <br /> (Applicant Marne) STREET1_4-440hpic <br /> AREA Rp-- QUAD <br /> v 4'LTYPE <br /> (Maiitng Address) FORMS <br /> ----- p —r— —� � NOTES --- <br /> (City,Stage,Zip Code) <br /> .2 0 `l <br /> (Area Code e elephone Number) <br /> F r k,ures ti, rash. <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to xcavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> of side of 1A1��4��ri ��� approximately be mile <br /> by performing the following work( escri tion of work): <br /> de <br /> Workwill commence on or about for approximately 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 /> �✓ ` "� 11 J <br /> ar1��1` 4 i Z� •� <br /> Signature ofAgpl' ant-Title <br /> IAICEMRALSERVICESa-ER'CAl1PUS-SV.WKVAASTEPPSIEWCROACHa1E14TPEFi,,IiAPpLICAnoKBOC(09113) <br /> 1 <br />