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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S� 2� Zm� OFFICE USE ONLY k <br /> 1 <br /> To: Sao Joaquin County JOB NCR## REF# <br /> --�—' <br /> Department of Public Works <br /> / y,( EXP.DATE 10-..t- 0 5( o DRIVEWAYS: <br /> ocsyP SO�.�fids ( PSt� 16-M4) VALID 9-!hv TO rD-(�`� <br /> (ApplicantNanie) STREET cv " <br /> AREA C QUAD <br /> 12`A3 TYPE not r <br /> (Mating Address} FORMS P 1 a sa l w I <br /> NOTES - -- <br /> Coc�curd CA "ty�21 — <br /> (City.state.Zip Code) <br /> (ajb) 983- 5f�a`-I i <br /> (Area Code-Telephone Number) <br /> II Sketch(Detailed plans may be submitted) <br /> � ,e.cxS2 S�2 Std MGp � �a� � Caf��ro 1 <br /> { <br /> i <br /> I <br /> ' <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County tiig Rg -of-Way on <br /> the Wei* side of t cc*_ .approxmately y a 0 fe mile Sok h <br /> t Y Serforming the following work ription of work): <br /> 1 Gro"r+c�v '<2i- Q Y�Cn , <br /> ane ('o t N C\L ciCe f� <br /> Work will commence on or about for approximalelY days. <br /> 1,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 with the rules and regulatoris of San Joaquin County and subject to inspection and approval <br /> I <br /> 43�.ry <br /> Holm _s1� <br /> signature o plicant-Title Date <br /> e nkW'uW43Fs'n1[T:'IOMMYFaYNta-+W1XL 0'�. <br />