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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PR/IINT: <br /> Date 2� 6✓ <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # / SZ-(p REF # V <br /> Department of Public Works APN CR <br /> EXP. DATE 9 IS O r' au <br /> (:�{ VALID / TO o(v "DRMWIC2 <br /> q� (Applicant Name) <br /> STREET �LF/�Lfl _ co* <br /> AREA SMietbra QUAD Z,r_ r-* <br /> FJ /� TYPE FLL Hole <br /> (Mailing .ALddresss)) FORMS _Stv�� k Z9 0 TS <br /> NOTE' <br /> �(CCity, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> t �t7� `L���aJ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ott�,erwise ncroach on County Highway Right-of-Way on the s de of <br /> f� V approximate feet/�tt <br /> of1114/0 ,Gta�} jby performing the <br /> fo lowing work- (description of work) : <br /> _Sf <br /> Pal -at <br /> Work will commence on or about for approximately <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, regulations of San Joaquin County and subject to <br /> inspection and approval . <br /> Si ature of Applicant - Title �-�ry�• Date <br /> nnsr e gees^tic. (s/oo) `E,UFIN PES TS TO: <br /> �ppr7��CE Q►"VBG BLD <br /> v�.y 1 <br /> 40�/ , ^- <br />