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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINK': <br /> Date u4l OFFICE USE ONLY <br /> To: San Joaquin County JOB# r o S REF# <br /> Department of Public Works APN CR# <br /> VALID ATE <br /> y 4 TO ( -3/-/ DRIVEWAYS: <br /> (Applicant Marne) STREET <br /> AREA TYPE QUAD _ <br /> (Mailing Address) FORMS <br /> -NOTES ------- - --- -------- --- -- - - <br /> (City,State,Zip Code) <br /> Brea Code-telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High' Right-oi Way n <br /> the side of 1- C Ea 1-� L-yc Pi)� approximately � c,-:, <br /> of ,,� r---- PP Y , fee ile� <br /> by performing the fo lowing work( escription of work): <br /> i�5 'i Gv <br /> Work will commence on or about for approximately 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 accords a with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> S gnai ure of Applicant-'1!Title /zZ, <br /> / ©ate <br /> f,IICEM%d.SER\ACEW-SICA1.1WdSV.tS'i'V.MTEkp.olCROACH?.IEI7iPM.IrrAPPIJCAT011DOC(om) <br />