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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# Z ,p2 REF.# <br /> Department of Public Works APN CR# <br /> EXP.DATE 57--1 <br /> VALID DRIVEWAYS: <br /> (Applicant Nanne) STREET r <br /> AREA1 E . �9 F E S�T TYPE r <br /> I t QUAD S� <br /> (Failing dress) -- FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> �11, y <br /> (Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C'( <br /> The undersigned hereby applies for ermission to excavate,construct andlor otherwise encroach on County Hi a Right-of-Wa .on <br /> the h side of approximately... 0� fee mile <br /> of v,,.�. - by performing the following work( esc6ption of work): <br /> Work will commence on or about for ap roima ly days. <br /> I,the undersigned,certify that I am the owner of the respective roe o ` I S <br /> work described above in accordance with the rules and regulations gulations o an Joaquin alCounty and subjent ct to inspection on ae owner and 9 d approval. <br /> ree to do e <br /> Signature of Applicant v Title IDate <br /> FAiCEN W"EWCEyy LMcAL1PUgyyvm&zTmpsexR0Acmie7TPQAIRAFPLJCAT1 mDoo(03/1 <br /> 1 <br />