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APPLICATIOM FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT.- <br /> -4�J-1 <br /> Date _ j�I� I S OFFICE USE ONLY <br /> 10: San Joaquin County JOB# -7 300 7 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE - ! <br /> C)QA)1 A ,9 I*E2 I C VALID - (-1 TO -( -(f' DRIVEWAYS: <br /> (Applicant Marne) STREET <br /> Ate <br /> — - <br /> AREA QUAD <br /> 1( E t;0 a 9 r) l/ �� t- ST TYPE T �-- - <br /> (Ililailing Address) FORMS <br /> � O/.� -NOTES <br /> (pity,State,Zip Code) <br /> i,V � l <br /> —(Area e-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C� <br /> The undersigned hereby applies fgrPermission to excavate,construct andlor otherwise encroach on County Hi ay Right-of Wa on <br /> the t�a�t side of y-) approximately �' fee mile k <br /> of ,by performing the following work escription of work): <br /> AR q <br /> 5 ` ' <br /> Work will commence on or about _ or approximately <br /> 1 5 1") y <br /> I,the undersigned,certify that I am the owner of the respective p e ,or m q alified 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 /> Signature of Applicant e Title ate <br /> FkICEMRALSEWCESICLERICAL'PUB-SV.WKVAASTERPSIEkCROACHAIEtJTPERM1iRAPPLICAi7CNDOC(0513) <br /> 1 <br />