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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date <br /> I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 23REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /Il-3/-(5 <br /> C O L j I=�O ZA)J AWflfEP�c )EL))QE VALID <br /> (Applicant Marne) STREET TO _ Z� : 3 / DRIVEWAYS: <br /> AREA fi/t QUAD <br /> brio L,91 11�'` S�. � - <br /> l a►lin TYPE p 1)/`)(Mailing <br /> ) <br /> ( g Address) FORMS <br /> NOTES _ <br /> (pity,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encr ach.on County Hi 1 Ri hf of Wa <br /> the WW1 1 side of � g yon <br /> of -( approximately ee mileo � <br /> by performing the following work(description of work): <br /> Work will commence on or about 5 <br /> for p Wmately days. <br /> the undersigned,certifOT <br /> )G 1y that I am the owner of the respective property,or am qua ified represent the owner and agree to do the <br /> o <br /> vork described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sfgna�eof <br /> 1ppant�Title <br /> Date <br /> %EMRALSERN""'LE'CAL1PUEI,WWh'AAS7ER.p51Q.CROACH91EtffPERih1(igppuCAll0k00C(09/13) <br />