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APPLICATION FOR ENCROACEMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ `�10� -1' G W� OFFICE USE ONLY <br /> To: San Joaquin County JOB # � 7� gEF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID. V_,J_{�g�Y TO-9045, DRIVEWAYS: <br /> {Applicant Name) STREET 9tia' <br /> !f®A•T71i*_ `M \ MTYPE �� <br /> e — <br /> (Mailing .1ddreess)* FORMS -2 . <br /> 5IYTQK�.. ,� �.._3y�1.� NOTE <br /> (city, State, .Zip Code) <br /> .� WA -%11 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> sk� <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach-on •County•Highway Right-of-Wayoa the sids:,of <br /> approximately feet/mile <br /> of by per€ormiiig the <br /> following work (description of:work) : 1GT''A\ l _ . \Lkauk' C%r fit` PVC_ - <br /> ' <br /> 7W 1 aR VA \Zu\ List CAUMR:WO 1'1 WA% <br /> ���• A a 'A�'LiVt'CY �D 3� 1.PP T • . <br /> Work will commence on or'about for approximately <br /> Q� <br /> days. . <br /> I, the undersigned certify. that I am the owner' of, the respective 'property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules. regvlat'ons 'of San Joaquin County and subject to <br /> inspection and approval <br /> 011 - Oa.. <br /> Signature of Applicant - Title Date <br />