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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> --- �� <br /> Date 0 f OFFICE USE ONLY <br /> 10: San Joaquin County Jos# 7�C O7 7 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 7 -1 —15; <br /> C [�1 1✓(2)QN1 AW79 I E12 c�- l2.0 1Q,C VALID - g- TO 7 1, -(5 DRIVEWAYS: <br /> (Applicant NaMe) STREET <br /> /too E . Q9 FIS Y E-Fj (" S-TAREATYPE ��� UAD <br /> (Flailing Address) FORMS 5j <br /> ,ST-0 L YL 1 ON � 95(D-0 5 -NOTES _ - <br /> (City,State,Zip Code) <br /> 6-2oq) j� toy <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for ermission to excavate,construct andlor otherwise encroach on County Hi Right�o�i Way on <br /> the Nor4>7 side of to approximately fee mile tr�csi <br /> by performing the following work escription of work): <br /> of <br /> J <br /> Work will commence on or about i S for ap oximately days. <br /> 7 r5��5 y <br /> !,the undersigned,cet#ify that I am the owner of the respective property, a qualifie 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 /> D � �- <br /> ignafrare of Applicant e Title Date <br /> FA:"EFtiRALSERMCESCLE21CAL1PUES-W-WKVWTERPSO,ICROACHMEt4TPERMRA(FUCATIOMDOC(09113) <br /> 1 <br />