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APPLICATION FOR ENCROACHMENT PERMIT <br />~.,:~(:-.;~l~:.['1 <br />I \"••,.......I'~.-'JS~,,:J •••••••,~:~.,I.I•.Jl;l"\I I <br />Dale <br />DRIVEWAYS: <br />• <br />• <br />,OFFICE USE ONI.Y <br />JOB#7$0077 <br />APN <br />EXP.DATE <br />.VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOlES <br />PLEASE PRINT: <br />!loaa E I-.-AFAtETIE ST(Mailing ddress) <br />~Y'YW ~8 I .1..J.')iLo <br />To:San Joaquin County <br />Department of PublicWonts <br />CA LIf:.DQtuJ A WATER/)E~Ill))Q.,E <br />.(Applicant Name) <br />-..sTO C-K.-Tb N 6q Q5<9.05 <br />(City,State,Zip Code) <br />~0\LJloY -~311_._.__10 :J(Area Code.Tefephone Number) <br />Sketch(Detailed plans may besubmitted) <br />• <br />The u dersigned hereby applies for Remiissionto excavate,constructand/orotherwise encroach.on County HilJh\\lll Ri9ht-1;-wayon <br />the,side of fY\INA.:a AiI~.approximately.fee mileM-+- <br />of .,by performing the followingwork escriptionof wort(): <br />Wont will commence on or aboul .for approlim~lelY days. <br />(S/'YIICt>f,the undersigned,certify that!am the owner of file respectiveproperty,or am qualified to re resenUheowner andagree to do the. <br />wort(described above in accordancewith the rulesand regulationsof SanJoaquin County and subjectto inspectionand approval. <br />clt.!,.(),,g (It Ik f):()~+,~C Q QN0 <br />.Signature of Applican!'Title