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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dater -- - ac;LI <br /> ; <br /> � OFFICE USE ONLY <br /> To: San Joaquin County JOB#Ap- '-7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE e-(- 0. <br /> . <br /> 4 L_1 -(1 A-)1 A i•EP.6-(�1�f C�,C VALID 2-k?�/'s ToC-/-lS'2ii/S' DRIVEWAYS: <br /> (Applicant Name) STREET X _ <br /> 1 C� E . QA F AREA S UAD _ <br /> -?I t- ST TYPE � <br /> (Hailing dress) FORMS <br /> ST-0 CIL T O N/ NOTES <br /> (City,State,Zip Code) <br /> 1 t it <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permissi n to excavate,construct and/or otherwise encroach.on County Highway Right-of-Way on <br /> the ` r side of � r Lc approximately_ 1'�s�� e ile �t <br /> °f �� by performing the following work( ption of work): <br /> r CA <br /> Work will commence on or about I is' for appro 'mately days. <br /> � Isis <br /> y <br /> C <br /> I,the undersigned,certify that I am the owner of the respective property,or am quali ied t epresent 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 o Title iate <br /> b"DEHiWdSERNCESICLEPJCALVUBSV.Wu4AsTEp PSENCROACHme4TPERA1RAPRICAT10?.000 ostn) <br /> 1 <br />