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APPLICATIOM FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> —1 San Joaquin County JOB# 7 REF# <br /> Department of Public Works APN CR# <br /> Wig <br /> EXP.DATE�La1 T (��1�1 ftTE d �EfU 1C,,- VALID TO DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> 1o l�.H AREA , AD <br /> I S� TYPE _ <br /> (Mailing Address) FORMSp <br /> NOTES �1� l <br /> (City,State,Zip Code) <br /> I, y --� f1 <br /> (urea Code-Telephone NuWber) <br /> Sketch(Detailed pians may be submitted) <br /> C \ aw C/ <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach an County Hi Right-of-Way on <br /> the .-� h side of approximately. <br /> of J fee mile E <br /> by performing the following work(description of work): <br /> Work will commence on or about 17 10 or approximately <br /> days. <br /> 1 rS r� <br /> 1,the undersigned,certify that I am the owner of the r <br /> espective property,or am quIlifiled 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 /> - - <br /> Signature of Applicant a Title ID to <br /> M:ICEMRALSBWCESICLERICALWBSv.WA1WASTEPPS1E7'CROACHNIETITPERAIRAFPLICATION.000(09113) <br /> 1 <br />