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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: p U <br /> Date <br /> 4 ` OFFICE USE ONLY <br /> 10: San Joaquin County J08# -73007 REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> &I 1 >=�(�t?/A�i A VA T-E 9= —5 110,L VALID � TO �-1 S-f 5 DRIVEWAYS: <br /> (Applicant dame) STREET <br /> Cof 1= _ AREA QUAD <br /> J9 YI E S 1 TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (C1ty,State,Z1p Code) <br /> (Area Code o Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> , <br /> The undersigned hereby applies far permission fio excavafe,construct andlor otherwise encroach.on County High Ri hf of <br /> Wa <br /> of � side of approximately• 6 fee i e �on <br /> by performing the following work scripfion of <br /> Work will commence on or about 1-19 <br /> r approximately days. <br /> 1,the undersigned,certify that I am the owner of the respective proper173 1 <br /> i,oramiq ifed to represent the work described above in accordance with the rules and regulations of San Joaquin County and subject toot owner <br /> a d and d app ovalree to do e <br /> ignature of Applicant d Title' <br /> b3Gi6 . <br /> 1•A_10ENTRALSERNCES1CLERICALll JBSV.yJ�AASTERpS1E1.CROACHA1EtJTPERNIITAppIJCATlON00C(03113) <br />