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06/26/2066 14:57 209468V-' SJCO PERMITS PAGE 02/02 <br /> APPLICATION FOR 'ENCROACHMENT PERMIT <br /> PLS$ -pxsiTT' <br /> Lute _ �'oO\o 'Gte'ICS, IIS" ONLY <br /> To: San Joaquin County JOB # R6£ # <br /> Department of Public works <br /> L+%P. DATS <br /> VALID. <br /> TO DarVXN&Ys: <br /> (Applicant Name) STREET , * . <br /> y � AREA QIIAO <br /> Aa 0701 \gyp\1�Y��°! t-+N"� t+ ��_ TYPE <br /> (Hailing Addreea) FORME. ., <br /> NOTE <br /> (city, State,'-Zip Code) <br /> (Arae Code - Telephone Number). <br /> Sketch (Detailed plana may be suhmitted) - - - - <br /> The undersigned hereby applies for permission to.excavAt6, construct and/or <br /> otherwise-encroach on- unty Highway Right-of-Way-oa-the Ja c %• s'ide_ofS <br /> approximately 2.n ee /mile <br /> of ar nw\ '�-.••.r, 1\p tl 6� f .e.:.Srt�C.k.6, by'performing the _ <br /> following work (desoriptioa o€.work) t s�ti <br /> Work will commence on or'about �1 \1,'c� for approximately <br /> daya <br /> I, . the undersigned certify that I am the owner' of,the respective property,. or am <br /> qualified to represent,the owner. and agree to do the work described above in . <br /> accordance With the. reQulations'of.San Joaquin bounty and subject to <br /> inspection and approval- <br /> . - Signature of Applicant Title Date _ <br /> tt <br />