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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 0 D 7 7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE - <br /> CA 1. N% A 9 TE V— <br /> `LU i CC VALID r3 - / TO - ( - ( DRIVEWAYS: <br /> (Applicant Narhe) STREET t <br /> 1 C� E �.I-� ti _ AREA <br /> -- . �. �7Tf- S-T- TYPE Igo ItAoIP <br /> (Mailing Address) FORMS FORMS—�✓ I'✓ j 7 °! <br /> ,STa L9 10 N � `7 5�� -NOTES <br /> (City,State,Zip Code) <br /> V —�s � 1 <br /> (Area Code e Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hig#� y Right-of Way on <br /> they t side of C)�-����� Q A i <br /> of \ �� approximately ' . fee mile AJOf-4 h <br /> by performing the following work( escription of work): <br /> Y�• r <br /> r <br /> Work will commence on or about 1 for approximately 5 — 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 /> i <br /> 3ignarure of Applicant a Title Date <br /> fA.- EGMRALSEWCEMMBL rCAL1PUBSV.WKyAASTER ENCROACHA1RdTPS;mUTAppijCAnORDo0G(09113) <br /> 1 <br />