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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> _ sat , <br /> Date � � I OFFICE USE ONLY <br /> To: San Joaquin County JOB# -3 002 7 REF# <br /> Department of Public Works APN CR# <br /> 1 ri/� _ EXP.DATE y^/- /s' <br /> C L C)R/L71 A V V TEP-c�L I'�(�}C�,(� VAL1D 4�15- - TO - /S DRIVEWAYS: <br /> (Applicant Hame) STREET �-Ja7t e I 4-y <br /> Roo c E . Q9 F AREA ;s� QUAD 4/S <br /> �I��I f` S� TYPE � � <br /> (Mailing Address) FORMS J5 <br /> - ,ST-0(L)0-0 N/ 9.S� NOTES - <br /> (City,State,Zip Code) <br /> (ao— <br /> '(Area Cede o Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> - ---------------- <br /> The undersigned hereby applies for per,mission to excavate,construct andlor otherwise encr ach.on County Hi Righf of Way an <br /> the ��'��tl�� side of � C'-,!c�.l,R.,�,�-m appra�ximatefy � fee mile <br /> of (1 - orf- �. - t--- <br /> by performing the following work escription of work): <br /> fflg�m� 4C6 <br /> _1 n of ��, .rte, <br /> Work will commence on or about f approximately days. <br /> t,the undersigned,certify that I am the owner of the respective pro pe ,or am qu ified 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 /> 4c-1ature of App rcant a Title Dqt <br /> Fd_1CEM'WLSERNCEWLEiICAL1PUM'W"L'AA5iII2PS'E1.CROANklEMiPMIITAPPLiCATIONDOC(09M) <br /> 1 <br />