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PPL CATION FOR ENCROACHMENT PERMIT <br />gLEAS�P�IN'i, 2 . <br />bate <br />To: San Joaquin County <br />Aepartmentof P`ubtlloWodcs <br />VUtl7"E c - ly, I@,E <br />(Applicant Name) <br />• {Mailing ddreasJ • <br />eA 4.SaD5 <br />(City, State, zip Code) <br />(Area Cada4%1®pfioneNumber) <br />08L-1 I .1; <br />The rinderstynedhereby applienfor pemiissfontoexcavafe, construct andtorofherwiseencroach onCountvHiaht vRtahtofWaydn . <br />Wodcwillcommenceonorabout I-�3 ?010. forapproxtnately <br />op 62u♦rir2 AvQ byperianitiggthefollowingwork ciiptionor.worlo: <br />is. <br />Lthe undarstdned,wdltythat Iamthe owner ofthe respeotivopropetty,oram.qualihedtorepresenttheownerand,agreetodoihe- _ <br />wodcdescdhed above in aecdrdancewith the mlesand regulations -of San Joaquin County and subjeetfo inspection and approval. • - <br />Signature efApplicant -Yi TO <br />1ICPIIIIW&RNC[SicleGopllNf&SUwnv.wsmeSe�NAtoAAiSiFllfPeP.44fAPPllontidtooa N`.yie) <br />OFFICE USE ONLY <br />JOB# <br />�f,�Q �7 REF# <br />APN <br />CR# <br />EXP. DATE <br />,r u <br />VALID <br />DRIVEWAYS:' <br />3TRE�T <br />�2.oSB✓fGT yT <br />AREA <br />r��A/QUAD <br />TYPE <br />zLGw16 `. <br />FORMS <br />?/mow P.L% —1;V,0 t,M!'�rr 0.0 <br />NOTESGnOGyGGVDITIpVS <br />•� <br />The rinderstynedhereby applienfor pemiissfontoexcavafe, construct andtorofherwiseencroach onCountvHiaht vRtahtofWaydn . <br />Wodcwillcommenceonorabout I-�3 ?010. forapproxtnately <br />op 62u♦rir2 AvQ byperianitiggthefollowingwork ciiptionor.worlo: <br />is. <br />Lthe undarstdned,wdltythat Iamthe owner ofthe respeotivopropetty,oram.qualihedtorepresenttheownerand,agreetodoihe- _ <br />wodcdescdhed above in aecdrdancewith the mlesand regulations -of San Joaquin County and subjeetfo inspection and approval. • - <br />Signature efApplicant -Yi TO <br />1ICPIIIIW&RNC[SicleGopllNf&SUwnv.wsmeSe�NAtoAAiSiFllfPeP.44fAPPllontidtooa N`.yie) <br />