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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /`tU - <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB _ 7, Q 7 <br /> Department of Public Works REF # <br /> APN CR # <br /> EZP. DATE - - G <br /> VALID. �'l INT-1 ��-! - o <br /> (Applicant Name) DRIVEWAYS: <br /> STREET ♦h + <br /> ® Autaa St ocY k,QTJAD <br /> (Mailing Address) <br /> TYPE <br /> L. t <br /> p �\ FORMS .Z <br /> NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be si3bmitted) <br /> The undersigned hereby applies for permission to.excavate, <br /> Otherwise-encroach•on Countconstruct and/or <br /> County..Highway Right-of-Way Oa-the _. const •• <br /> of }J� , approximately -- f/® ide:.Df- <br /> .S'} Imi1e �.c <br /> following work (description of;w ) • by per€ormiiig the <br /> • � )�6'� C=��L �'� - - _��s�.I/ <br /> U <br /> Wo11 commence on or'about 14 <br /> b <br /> days.•_ for apPrOximately <br /> I, the undersigned certifY. that I am. . <br /> the owner' Of. the respective property, or am <br /> ent the <br /> qualified to represowner and agree to do the work described above in <br /> accordance with the rules, regulations •of <br /> inspection San Joaquin County and subject to <br /> and approval.. <br /> �-S��,r •ems � ._ r�.��. • ' .•, _ <br /> Signature of Applicant <br /> - Title <br /> ate <br /> XSTR1Z-!?9k BS®DL <br /> • t <br />