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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date q -1;; - 17 <br />To: San Joaquin County <br />Department of Public Works <br />T10aN ICA 12 WE - s- r_o]2i aCiON <br />(A5plicant Name) <br />2,1 ..S CUMMC iZGI: 9FIGS <br />(Mailing Address) <br />Nk l wA r2 n G,eq, q y 5 y_5 <br />(City, State, Zip Code) <br />ala -3&q-62"7' <br />(Area Code - Telephone Number) <br />_DO60A/LuFZL AQ -k.4 --4M:r&2Ro$'1oAJ-GDM <br />Email Address) <br />Sketch (Detailed plans may be submitted) <br />SCC �✓�G��'i� <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP.DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the N t .S side of E, oRcNA12o RD approximately feet/mile <br />of , by performing the following work (description of work): <br />DPfLL Ty Sme[rAZL zw'r' aG0,il- *'%V CATHonV- WELL Ong tifJ(iai DF i3ORz AA12L) 0P. TOJ6 LI'* 4' ajaL 14a <br />ytA-),.i'OSE P6i9-P'o'n6INE no12EAPVO Q Qd2A 0 'ZIV PO 12 CVI'JDdI; <br />To 04/N PNo%1t •t 1 Efi Ua&El X1JCt U Pow6RNarJsc` G(-)rirn�E; ons �"%siDt ar RoAn --rip N L&,,' <br />Work will commence on or after _9 <br />for approximately iE ,1yA2yttJ6 days. <br />I, 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 />�� ��,�-a✓�ra� s�nr=Ryrsv� 9- P3 - I <br />Signature of Applicant - Title Date <br />YI-ORMS 8 TEMPIATESIENCROACHMENT PERMIT APPUCATION.doc (008) <br />