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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> f OFFICE USE ONLY <br /> 10: San Joaquin County JOB REF.# <br /> Department of Public Works APN l./ OR# <br /> ti • <br /> _ EXP.DATE 7 —� _j �• <br /> Cog t_I T-� ('��/�j A 1 � �`IZ I IE VALID S -1 - 1 S TO Z- 1-15 DRIVEWAYS: <br /> (Applicant Name) STREET phi, rs r""C1I A/ <br /> AREA �to o QUAD �_ <br /> 1( E . �A� 1✓7 E S� TYPE 11 h n i P <br /> (bailingAddress) FORMS <br /> �T L K-f © N NOTES <br /> 9 5� <br /> (City,State,Zip Code) <br /> toy <br /> '(Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies fo ermission t ex avate,construct and(or otherwise encroach.on County Hinfee <br /> ight-of-Way on <br /> the wR�t side of � on(� approximately ile <br /> of <br /> by performing the folio wing work(description of work): <br /> 111 d <br /> �n <br /> �'. l <br /> Work will commence on or about i �' <br /> or approximately days. <br /> I,the undersigned,certify that I am the owner of the respective p e ?or am aliffed to represent the owner and a ree t <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approoval.e <br /> gre o ApptoT� � <br /> q6r <br /> e <br /> M:10ENiRALSEWCE51CLEPJCAL1PU3S"VkVAASTBUS�CROACHMEt PERhIfTAPPUCAT10N.000(0113) <br /> 1 <br />