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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 21-L' Z I b OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3IqLot0 <br /> l o 2 e/o �, r�u �.� s;5 r,.,c . VALID ! ;LO16 TO SMA010 DRIVEWAYS: <br /> (Applicant Name) STREET oil f 1 ' <br /> AREA t� WAD <br /> /o-CA 5+,e e TYPE am- 7--EtN10Vm_,'4r— y7lRT6Q <br /> (Mailing Address) FORMS 1A0 1..) a WELG� <br /> NOTES <br /> LA 953zo <br /> (City,State,Zip Code) <br /> Izoal g35 -`lis E, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) 5 ,.,r;814, <br /> key Is <br /> .0 <br /> s <br /> g9 �i � � <br /> tJ <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the e o Y5 - side ofTj JI� 9A. 8��approximately �S ee mile v o-+-(-,of + , 19. 01 ,by performing the following work(description of work): <br /> 2 �'a : ^ �^w.: w:,� �ll Mv� f2.S v.�— ro✓�-;.. w: n �. P H-e,n. <br /> F e✓� v q� 5 J 1 t L49 d .✓:1-ti� •to�,' u 1 <br /> Work will commence on or about ja I e 1,v-vo, for approximately \ vim 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 /> 1, V - 5`F Z��f 1 0 <br /> Signaf r Applicant-Title Date <br /> E'IPUB-SV.K'NVMSTER.PSIENCROACHMENTPERMITAPPLICATION.DOC(01M) <br />