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APPLICATION FOR ENCROACHMEM T PERMIT <br /> PLEASE PRINT: <br /> Date . � l <br /> OFFICE USE ONLY <br /> 10: San Joaquin CountyJOB# � 7 REF# <br /> Department of Public Works APN OR# <br /> C _ EXP.DATE <br /> 1(�R fl I_E )Q,1_ VALID 6 TO 51- 5-!S DRIVEWAYS: <br /> (Applicant NaMe) STREET <br /> 1 = _ AREA S7`�I- !n QUAD 5 <br /> C� �, ]� . Q9 F) E f 1 TYPEP -- <br /> (Rilailing Address) FORMS ; ] -2 <br /> O.J NOTES <br /> - - <br /> (Clty,State,ZIp Code) <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroa on County Hi Right�of Wa on <br /> the_ . side of approximately <br /> of ]1 s� fee mile car <br /> by performing the following work(description of work): <br /> Work will commence on or about (P <br /> proximately days. <br /> plimfor <br /> f,the undersigned,certify that 1 am the owner of the respective gropeuali ed 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 /> SIgnaLM gf Applicant o Tlfle I <br /> to - <br /> fd_10EMRALSERNCE51CLE21CAL1PUHSVWKI.tASTII2PSIE?.CROACN.47ENTpFfttdlTAFp�CAi10ND0C��9713) , <br />