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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I OFFICE USE ONLY <br /> To: San Joaquin County JOB# IP } C� ' REF# <br /> Department of Public Works APN CR# <br /> ` w EXP.DATE kr' <br /> f)i_ T C)2N i A VV1, R VALID - i t TO _` -' DRIVEWAYS: <br /> (Applicant Marine) STREETAREA <br /> E . "F)9y E� E ST TYPE ; AD <br /> (Mailing Address) FORMS ,S_ ��1 A`,,� �2r tv��►cL. ��U<<c� <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code o Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hi i a Right- -VVay,on <br /> the r�F h side of Cru en n t ..,/"� approximately t a�'� fee mile f- <br /> °f by performing the following work(description of work): <br /> 'Z3 17c o <br /> r `f s Z. <br /> Work will commence on or about I 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant e Title I ate <br /> F lcEgMALsumcEsIcLmcALMB-svwk'v ASTER.PSIEkcROACHA7ENTPERMRApFucAnomDoC(OJ13J <br /> 1 <br />