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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date r E� <br /> OFFICE USE ONLY <br /> lo: San Joaquin County JOB REF' .# <br /> Department of Public Works APN CR# <br /> ,�/� EXP.DATE <br /> C <br /> A t_I l 1 C)Q/11)I A `Y V �I Ep. : o l OLE VALID � �'�� 1TO ' -i.-2a DRIVEWAYS: <br /> (Applicant Narhe) STREET A - <br /> AREA e�� QUAD - <br /> 1(ri chi . �./9 F )9 E-7 j t-- Ste" TYPE <br /> (Mailing Address) FORMS w � i <br /> �To L)L i' ON � Oy J t_0 NOTES <br /> (City,State,Zip Code) <br /> 10 y <br /> (area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County H=- <br /> theighf-of Way on <br /> ��{ side of J—r ��,� approximately _ ile��k <br /> of no rn�} by performing the following work(description of work): <br /> - 2 <br /> Workwill commence on or about l for approximately_ days. <br /> y <br /> 1,the undersigned,certify that I am the owner of the respective rope ,ora qualified 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 /> 41-5 <br /> Signature Of Applicant-Title I Qte <br /> FA:ICEFITRALss; ICESCLER'CAL)Pu&SV.WIvAAsTERPsieTcR0ANme4TPERMRAPPUCAnONDOC(0siq <br /> 1 <br />