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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: } <br /> Date - <br /> L o2C�) OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 00 77 REF# <br /> Department of Public Works APN _ OR# <br /> `,� _ EXP.DATE <br /> C l�I 1 (`�EN 1 A Y V 9 I-t iZ c�L(��l C,L VALID TO j _ 5 DRIVEWAYS: <br /> (Applicant NaMe) STREET , ✓ - <br /> _ AREA 0 AD <br /> 1� _ <br /> o R E �./9 F �� 1✓-7 f" ST TYPE , <br /> (Mailing Address) FORMS <br /> NOTES <br /> - OL1C) © N/ gJam. <br /> (Clty,Mate,Zip Code) <br /> 2, 1, y - � <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for ermission to excavate,construct andlor otherwise encroach.on County Hi I Right of-Wa on <br /> fhe side of—'-. i n approximately f fee iI <br /> of <br /> by performing the fo owing work(description of work): <br /> Id 0(13 <br /> Work will commence on or about fi approximately days. <br /> I,the undersigned,certify that I am fhe owner of the respective proper(}r, r am qu fed to represent the owner and agree to do the- <br /> workdescribed above in accordance with the rules and regulations ofi San Joaquin County and subject to inspection and approval. <br /> lgnatura®fAppllcant Title qte <br /> MA"'EMRALSERM ESICLE21CALVU&SV.WKLAASTERP51aCROACN91Et4TPERh1RAPPLICAT70N.000(09113) <br /> 1 <br />