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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: � Roo)Date <br /> _.)oJQ all OFFICE USE ONLY <br /> To: San Joaquin County JOB# _7300 77 REF# <br /> Department of Public Works APN _ CR# <br /> _ EXP.DATE _� - <br /> &L�1 T('7 A-)1 A f I�� �(`(�(� )C,[ VALID ��- ( -/ TO DRIVEWAYS: <br /> (Applicant Madre) STREET T Its/ <br /> AREA QUAD <br /> — <br /> 1 0 a E . Q9 Y *E &T' TYPE — <br /> (MailingAddress) FORMS �r <br /> n < S/In/tai,ems <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Cade�Teiepl�®ne dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County H' Right-of-Way on <br /> the�/oY�}h side of_ V �] approximately fe ile <br /> of 1. P)QLf , 1 <br /> by performing the following work( escription of work): <br /> I X vl C5 <br /> Wori<will commence on or about or approximately <br /> ! 5 days. <br /> I,the undersigned, certify that I am the owner of the respective properly,or am q alifed 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 /> 14? 1 <br /> Signature®f Applicant-Title <br /> Late <br /> PAICEMRALSMR ICESCEMCAUPUBSVWIvAASTULPMMCROACHA7EtTPERAIITAPPIJCAl10N.00C(09113) <br />