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APPLICATION FOR ENCROACIVIMENT PERMIT <br /> PLEASE PRINT: <br /> DateE O " <br /> P OFFICE USNL <br /> To: San Joaquin County JOB# 730077 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE I S <br /> C fl L_ <br /> LE Lk-l JqW19!EL? QE VALID �-�J TO _h-�_S�S_ DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> t <br /> I= AREA QUAD _ *:�—1 <br /> .�. <br /> (Mailing Address) � S�" TYPE W 7 9 r�"D,^�1, <br /> NOTES �Pll�C e <br /> C'A 95<D-05 <br /> (City,State,Zip Code) <br /> �a L/ ---� i r <br /> (Area Code a Telephone Nurnber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ped hereby applies for p mission to excavate,construct and/or otherwise encroagh on County Hi Right-of-Way on <br /> the h side of t r1 �' approximately <br /> of fee ile _ <br /> by pertorming the following work( escription of work): <br /> RP <br /> _ �t l Q30CS )0 <br /> C. #, X* -�' <br /> Work will commence on or about _f r a prox' ately <br /> days. <br /> `t > >S <br /> I,the undersigned,certify that I am the owner of the respective property,or am all ed to present 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 Iate <br /> M.'ICENRALSERVICESICLERICALIPUB-SV.WKNLASSERPSIENCROACHmE1drPER61RAFPucATiokDCC(0°J13) <br /> 1 <br />