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'r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # / 0615- REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE D <br /> :res Tr. h K1 e VALID 3 O DRIVEWAYS: <br /> (Applicant Name) STREET . <br /> 55 I KG.S So n (o <br /> AREA <br /> E �y QUAD � <br /> (Mailing Address) FORMS <br /> NOTE <br /> 9 V?o <br /> (City, State, Zip Code) <br /> Czobc►�- aog- <br /> «b9-3a�• <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) m o > <br /> - Z <br /> -a rn <br /> O .33. 0;Q <br /> t+J C Ml <br /> r7 "o <br /> C-) <br /> 7R <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County Highway Right-of-Way-on-the side-of <br /> Kai&gr proximately -70n feet/me Nor j 11 <br /> of Duria ..srf Z by performing the <br /> follow, work (description of: work) : /C 03 <br /> o"dw4'S rt wore <br /> dee o ,O c✓6 Mlr/f-. <br /> Work will commence on or'about th&rch 2dU-0Lfor approximately <br /> 3 Oa v S <br /> days. <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 rules, regulations 'of San Joaquin County and subject to <br /> inspection and approv <br /> 3 �3-L <br /> S of <ppiicant Title Date <br /> HASTER.PS\HBBS®L (6/00) <br />