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APPLICATION FOR ENCROACIMENT PERMIT <br /> PLEASE PRINT: <br /> Date /0 3 <br /> OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 77 REF# <br /> Department of Public Works APN CR# <br /> f _ EXP.DATE _ o ' <br /> C <<! T 0 ens I A V V TE P— () 1 I[ VALID -I TO - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 1�o R E . QA Ffj Y/ E-rl •(-- S TYPE [tin 1 e <br /> C (Mailing Address) FORMS <br /> 1 � O S � -NOTES <br /> K- © N <br /> (City,State,Zip Code) <br /> .r y -- i t <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for ermission to e cgvate,construct andlor otherwise encroach on County Hi Right-of Wa <br /> the side of approximately flee mile <br /> of by performing the following work( escription of work): <br /> �j� OcoOa <br /> A __ y — -Z <br /> T1) 1 <br /> �nQQ+ las on <br /> Work will commence on or about ! r I _ or approximately 4oi days. <br /> ],the undersigned,certify that 1 am the owner of the respective property,or am lified 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 e Title Date <br /> M"'CEMRALSERVICES1CLEMCAUPUBSVWKIAASiFRP51ENCROACH,1E"PERMITAPPLICA770N.D00(09113) <br /> 1 <br />