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;.0003¢ . <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PSINTPRINT, <br />,Data 0 <br />To: San Joaquin Gcunty <br />department of Public Worlm <br />(AppiicantNadreI <br />r='j-T-Li C�: sr' <br />{MailingA�dressJ <br />(City, state; zip Code) <br />(Area Code=%lephone Number) <br />♦;6: <br />Thoundersignedherehyappliesforpemiisstontapxcavat2,cgnsiructapolorotheiwisoencroacfi.onGounfytligh Righf-ofWa on . <br />the WeS�_^Sldeof N QI��� A�� approximate(yya1 e Miley{�• <br />az f11��c}1P S }- by performing thefollawing work (esciiptlon of worlo; <br />Vllod<wi[Icornmencaonorabeufi I- _forapproximately days.. <br />I, the undersigned, certlfythat I am the owner of the rospeotive, property, or am qualified to representthe owner and agree to do ihe- <br />work described above in accordance with the rules end regulations of San Joaquin County and subjeotto inspection and approval. • <br />��%-oti•- �s CIT <br />Signature ofApplic t•Titla <br />LICEHINd&kRl7CES.gHdCpL1FUg5V.W1."�dO51FAP.t'E4tR0ACItUgIfPfPAJfAr]uCA7NRICCO rn9113) <br />OFFICE USE ONLY <br />JOB# <br />/, ^j�J REF91 <br />APN <br />CRif <br />EXP. DATE <br />/.b <br />VALID <br />Ojai, O' S I p' <br />DRIVEIWAYS: <br />STREET <br />E ►ff <br />. <br />AREA <br />QUAD XS <br />TYPE <br />60 adoS <br />FORMS <br />c zZ SsAiw✓ �i E <br />� Flo%v& �> <br />NOTES <br />�`'cipLGd' �rnoAJs!'• <br />Thoundersignedherehyappliesforpemiisstontapxcavat2,cgnsiructapolorotheiwisoencroacfi.onGounfytligh Righf-ofWa on . <br />the WeS�_^Sldeof N QI��� A�� approximate(yya1 e Miley{�• <br />az f11��c}1P S }- by performing thefollawing work (esciiptlon of worlo; <br />Vllod<wi[Icornmencaonorabeufi I- _forapproximately days.. <br />I, the undersigned, certlfythat I am the owner of the rospeotive, property, or am qualified to representthe owner and agree to do ihe- <br />work described above in accordance with the rules end regulations of San Joaquin County and subjeotto inspection and approval. • <br />��%-oti•- �s CIT <br />Signature ofApplic t•Titla <br />LICEHINd&kRl7CES.gHdCpL1FUg5V.W1."�dO51FAP.t'E4tR0ACItUgIfPfPAJfAr]uCA7NRICCO rn9113) <br />