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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> II AREA QUAD " <br /> 30y3 fa c,ld t,L,�-�n G--1 �1-i Ys� `7 L,vi'C�— o��>I TYPE <br /> (Mailing Address) FORMS <br /> \\ � , NOTES <br /> CC0>-dc7 V('...., le^i ` 1 7 5 LC' D <br /> (City,State,Zip Code) <br /> `3 33 LV <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) & y� <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County High y Right-of-Way on <br /> the side of approximately I;RO s -L�I U keUrnile W ti <br /> ofbyperformingthe following work(description of work): <br /> vn 44. c71 7 cc= <br /> Work will commence on or about for approximately 2 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 describ dab in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 9171z0 <br /> ,//2 <br /> Signa ure Applicant-Title Date <br /> G <br /> AHCEMMLSEPVILES0.FFIC.LLIRI&SV.NiCW31ERV5Ef1CR0ACMIFNf PF1NtM0.1CAiKK10R �W1d) <br />