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APPLICATIONFOR ENCROACTINiENT PERMIT <br /> PLEASE PRLti-T- <br /> Date Z - 9 - q5 OFFICE USE ONLY <br /> JOB #�&j20 REF# <br /> ATN - CRV# <br /> To: San Joagam County Highway Department EXP DATE <br /> VALID DRIVEWAYS: <br /> V Gro ndwa�rX STREET Gflvv r�orK4., : <br /> (Applicant Name) AREA QUAD /V GcJ <br /> TYPE_ r m � # <br /> IL40I Yalyavd Dv. . 14DL ! FORMS SS k.w <br /> (Mailing A dress) NOTE <br /> WtS4 Sa ceawttvcto r LA gS191 <br /> (City, State Zap Code) ! <br /> lIto — 3lfi-4700 �� o/�tal[ + t" <br /> (Area Code-Telephone Number-) - holt M C41"4 Z,aQd <br /> Sketch(Detailed plans may be submitted) Lice a�N-ach cct P WA A ) — 1,%i — I <br /> to ca-ho Ms are_ �a I s kkaA- rc.gtkrec th cvoadow-jot Pj'VM i�s <br /> 45 �e✓ o v 6onvwsa-He ✓i o v+ r---c-6 vuqvy <br /> The undersigned hereby applies for permission to excavate, construct an /or otherwise encroach on County <br /> Highway Right-of Way on the K*5 Ci.W side ofjda A y,� 17-AovK1PPf R zd approximately <br /> feet /mile bf , , by pmfo=nia8 the <br /> following wow (description of work / t <br /> ygw 146 WN AW <br /> 19?" 40r ,t -4o a,--. Alork eAqz&Ai 014C�ri�J Z.S-!H <br /> G Q ►r .. r 1 r Il <br /> S j K Q Ivr` i J �' <br /> Work will commenceon or about Fc-6 ria•-y No-, 1 R9 S for approximately _days <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br /> agree to do the work ciescribed above m accordance with the rules, regulations of San Joagwu County and subject <br /> to inspecton and approval. <br /> �`t <br /> 7yG—NZATi&E OF APPLICANT - TITLE A <br />