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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date + � � I `mac rl <br /> OFFICE USE ONLY <br /> 10: San Joaquin County JOB# P.0C-X17 REF# <br /> Department of Public Works APN OR# <br /> EXP.DATE .-IS- 2-0 <br /> C 19[_ I=�(")��t A 6 1_E�c�l_.1_2r.�I IE VALID f�_-�__ Zd TO / -2 y DRIVEWAYS: <br /> (Applicant Naite) STREET <br /> 1 o . �. 9F ` E J S-T, AREA TYPE QUAD <br /> (Mailing Address) FORMS <br /> C k9Q-ire <br /> �- _NOTES — <br /> (Clty,State,Zip Code) <br /> (urea,Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andfor otherwise encroach.on County Hi hway Right-oi Way on <br /> the' i��,�F side of cis approximately f e mile <br /> of <br /> by performing the following work(description of work): <br /> 205 S. Sr,nc��n► �, u e_ <br /> Work will commence on or about -for approximately <br /> days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am <br /> is- , <br /> 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 Tilde <br /> Dat <br /> fL\CENnIMSEWCESCLEPJCAL)PU&svwKe4ASTMP51ER'CROACHME14TPERMRAPPLICADORDOC(09,73 <br /> 1 <br />