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APPLICATION FOR ENCP®ACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dater+ ,�,`� �I �J OFFICE USE ONLY <br /> To: San Joaquin County JOB# � r� REF# <br /> Department of Public Works APN CR# <br /> W EXP.DATE -(R.� / ._ 1�A t_11✓• Cti�/�1 A 1 I EP,c�- (_L?IE VALID -TO-' dDRIVEWAYS: <br /> C <br /> (ApplicantNan�e) STREET rt�kj� flv� <br /> 1 <br /> _ AREA i UAD C_�U 0 chi, E ;~/9 FM V E T t~ ST TYPE <br /> (I111ailing Address) FORMSLA} <br /> T-0 L)L 10 N c. NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for p mission fio a cavafe,construct andlor otherwise encroach.on County H" a Right of Way on <br /> e <br /> Of <br /> ---�- by performing the following wor ption of work): <br /> 'o C. <br /> Woric wi(I commence on or about � � or approximately <br /> days. <br /> y <br /> f,the undersigned,certify that I am the owner of the respective pro ,o am q lified 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 /> Signature of Applicant Q Title I Da,e <br /> MA'ICEMRALSERMCESlMEpiCALvuaSV.WKVASTUpS E�CROACHMEtJTPERMRAPp1.ICAMON000(09/13) <br /> 1 <br />