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14:4^ TE I CHERT CONSTRUCTION 4 4689324 <br /> N0.557 D001 <br /> / e � �f <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Q OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE �o <br /> 1 T2� <br /> =f j VALID O /Z /S DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA !9"10,e QUAD <br /> y aY y T" , its �r <br /> (Mailing Address) FORMS <br /> NOTES <br /> cksz�► <br /> (City,St ,Zip Code) <br /> �e3 <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 n County High Right-of Way on <br /> the t� side of_ f= approximately C�C� �ile <br /> °t—��'��—�--� -- by performing the following work(description of work): <br /> Work will commence on or about b fora approximately <br /> y <br /> 1,the undersign certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work de bove in accordance with the rules and regulations of San Joaquin County and Nect to inspection and approval. <br /> Fri <br /> Signature of Applicant-Title Date <br /> E?PUP3V. .P9IB/CRY,p11ENf PEiIAiR awLwr�Cx:AOC N7A6; <br />