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APPLICATION FOR,ENCROACHMENT T PERMIT <br /> PLEASE PRINT: <br /> Date <br /> "`�'"� 1 �-� !'� -[--OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 ?j Qy 7� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> I'tV_ �1 (L�iC,L VALID ? 2 (S TO ls'-!S DRIVEWAYS: <br /> (Applicant NaMe) STREET <br /> _ AREA QUAD <br /> (o o c�, E 1�9 FM ��E 7I f ST TYPE <br /> s <br /> (Flailing Address) FORMS <br /> - T,SO C_ K 1 ©N �7.J NOTES _ - - <br /> (Ciky,State,Zip Code) <br /> 6a0_ jt Ia y --L � f l <br /> -'(Area Cede-Telephone Number) <br /> Sketch(Detailed plans maybe submitted)_. - <br /> The undersigned hereby applies for rtnissfon to excavate,construct andlor otherwise encroach.on County Higl Right-of-Way on <br /> the ray �-F side of ��r�1n i o ( � approximately ee ile <br /> of `T�h n - 1, by performing the following work(description of work): <br /> l <br /> Work will commence on or about a- I fapproximately da s. <br /> �} �S f y <br /> 1,the undersigned,certify that I am the owner of the respective prc petty,or a qua fied to represent the owner and agree to do the- <br /> work described above in accordance with the rules and regulation€ of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant o Tike I Date <br /> M-"'E"V"ERWCES1CIMCALNPUMV.W?aASTER.PSE7�CROACH97ET.RPEalFrAPfUCAnOMOOr(OaM) <br /> 1 <br />