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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> -* �G 3 9 <br /> Data _ �� oZQ 1 �� OFFICE USE ONLY <br /> 10: San Joaquin County JOB# _ 71 — REF# <br /> Department of Public Works APN CR# <br /> L- <br /> )RA-) <br /> EXP.DATE -(5 ZU j <br /> L_1 T= A-)l A I�fZ c� (�('1 CL VALID ? TO a/! DRIVEWAYS: <br /> (Applicant blare) STREET <br /> v <br /> 1�ri 0 E . �fl FM y E-� f` -T� TYPE QUAD M E <br /> C (Mailing Address)) FORMS <br /> (!2A `7., Q NOTES _ - <br /> (City,State,Zip Code) <br /> 6�'-Q L/ 3 <br /> (Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ----------------- <br /> 2-- 3 tOM . <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach.on County Hi9l way Right-ofWay on <br /> the I�l�n+ side of r approximate( <br /> of�— J,�ocn� Y , fee mile <br /> by performing the following work( escr ption of work): <br /> n� <br /> Work wi[I commence on or about f ap roxi ately � <br /> days. <br /> y <br /> ' 1,the undersigned,certify that I am the owner of the respective property,or am qu ife. to re esent 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 Appllcarlt Title <br /> Qate <br /> M:ICENTRALSERVICEMCLE2CAL1PLIBSV.WKRAASTERPSM%,CROACH.k Er4TPEFMI[TAPPLICAT70t1DOC p113) <br /> 1 <br />