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APPLICATIOM FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datea OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 7 300-2 2 REF.# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> =(��A-)I ! V V 1�fa Q c�L IZU 1 Q,l= VALID - -[ TO DRIVEWAYS: <br /> (Applicant Mane) STREET � - <br /> 1( <br /> _ AREA .^- QUAD 0 E Q9 R9 � E I F S-TTYPE <br /> (E1ailing Address) FORMS f (41 <br /> NOTES <br /> (City,State,Zip Code) <br /> a y —� 1 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby appffes fo permission to excavate,construct andlor otherwise encroach on County Hf Right-of-Way on <br /> Lha. Ns)r �'h side of Eu ' approximately r fee mile LCA�f <br /> of rn �_ , ,by performing the following work criptfon of work): <br /> G 1 <br /> 1 ��-11c�o •tet <br /> LA ��xy , T- <br /> Work utli[l commence on or about I 15 for proximately days. <br /> 1,the undersigned,certify that f am the owner of the respective p petty,or am qua(if d to represent the owner and agree to do the <br /> work described above fn accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> e11aA io 4ED <br /> Signature of Applicant b Title <br /> FA:10ENTRALSERVICESCLERICAUPUSSV.Wht'AASTERPSEk-CROACH97EHTPERh1RAFplicAnOMD0C(09113) <br /> 1 <br />