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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> JOB# REF# <br /> To: . San Joaquin County <br /> /1� <br /> Department of Public Works API CR <br /> EXP.DATE t VOID DRIVEWAYS: <br /> ,fin! G,�lruG—J �" VALID r TO <br /> (Applicant Name) STREET �x-�tu�r�� <br /> pp <br /> AREA QUAD --!!56V------- t <br /> � __-�'>2r�✓�- /'L�idY _ TYPE ( t ✓✓)9Lk <br /> (Mailing Address) FORMS ('w G4 <br /> NOTES <br /> (City,State,Zip Code <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> lfS�acr�K►r�r� 1.��/ �°R�Dg1�D<'S"'I�f'„� <br /> a on <br /> The undersigned hereby applies for permission to excavate,construct and/or otherJdise encro n on County Highwe Right of-W <br /> the �".�crT- side of x�yl�GT6 4"9- approximately �� <br /> of,�' ---� �� .��1 ,� ` / ' by Performing the following work(description of work): <br /> Work will commence on or about for approximately days. <br /> I, the undersigned, certify that i am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in accordance v,,ith the rules and regulations of San Joaquin County and subject to nspection and approval. <br /> 4nafiure of Applicant-Title Date <br /> y'F0.7M5 L TEMPLATES tl CIHNENT PEWAR APP±IGTIrN„c JOWS] <br />