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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> / P5 - 40 33 <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# ��f�' REF# <br /> Department of Public Works APN _ _ CR# <br /> 17e5 -4- <br /> � EXP.DATE <br /> ` <br /> � 4�!��J VALID -L4T0 _ _(S - (s DRIVEWAYS: <br /> (Applicant Name) STREET , <br /> 11A(( L d P ka <br /> <— AREA Lod, WAD /(/t <br /> /L31-1,S/Q 51 , <br /> TYPE t2yre <br /> (Mailing Address) FORMS S��_�j/�/ � <br /> NOTES <br /> l CIS s vs-s5 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or,otherwise encroach on County Hi('Right-of-WaLon <br /> the i\14'X010 sideof_tU��� �if�4`�g �'� aproximately 20 fee ile 4�5dSi <br /> of 9 /V, F �.�i r is lcrl L ryi D by performing the following work description of work): <br /> i t r CO <br /> .n5-,4-4 a►i C-oa C-,4 v 3&zcIyi 6E�' <br /> Work will commence on or about )/-- 7--• /Y for approximately X20 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 /> A, / 14 <br /> Signa ure of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSENCROACHMENT PERMIT APPLICATIONDOC (09/13( <br />