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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> SJ� <br /> Date (} OFFICE USE ONLY <br /> 10: San Joaquin County SOB# 7 3—f� ] REF.# <br /> Department of Public Works APN OR# <br /> _ EXP.DATE Y--/-/;1 A V V 19—E Q�)Ef .W Q E VALID � 'ZU-1 S TO -f_ s DRIVEWAYS: <br /> (Applicant Naie) STREET - <br /> AREAg���_ QUAD - <br /> x-- 19 F ��E�I �- ST TYPE 7� l f 111-0 ; <br /> (Flailing Address) FORMS S S 141)AZ > �I <br /> NOTES <br /> (City,State,Zip Code) <br /> � 1I, y --� � t 1 <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for per i$sion to excavate,construct andlor otherwise encroach on County H' Right of Way on <br /> the <br /> �J�sid e of �1 approximately )6 fe mile �� <br /> of by performing the following work escnption of work): <br /> v� <br /> Work will commence on or about fora proximately days. <br /> f,the undersigned,certify that 1 am the owner of the respective property,or am quali led 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 /> 1�;ti+1 �; <br /> Signature of Applicant 4 Title Date <br /> M:ICENIRA(SERNCESICLE21CALlpI13-St/,Wf,1.fA5TER.p51E1.CR0ACHAtETtTpERhlfigPpICATi0N00C(09113) ' <br /> 1 <br />