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APPLICATION FOR EN0,ROACEMENT PERMIT <br /> PLEASE PRINT: <br /> Date ( -31. O 6 OFFICE USE ONLY <br /> To: San Joaquin County JOB # II REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 22 p <br /> De.,S ; 1.,A Crp.+6S Go�+s'�ruL�-ioN VALID 3 23 TO 3 2.4 0-1 DRIVEWAYS: <br /> (Applicant Name) STREET I.JY y 6E RD. <br /> AREA s-ne-h QUAD 1(� <br /> itSSS- Dybi;n gtyd. TYPE 4-- <br /> (Mailing Address) FORMS <br /> NOTE <br /> Ga 9ysbs <br /> q�(Cty <br /> , State, -Zip Code) <br /> 9 o285 <br /> Te-s a <br /> (Area e - Telephone Number) <br /> Sketch (Deted plans may be submitted) <br /> a6m4,r dcd1� te+u,( \ 4k.. e�,4e.k 4- 4s O✓t9l✓ia�.�o{ �xft<ei �I�aK co»c�t�a>, ✓t b✓ �a <br /> a A•r1rArC.kF_4 P►tills Gr <br /> ,+ Lr,4 C-4r Qo. 10- 3 A 430y II 5ha� /I <br /> O burino� bo �v �+lcJ c(>ef,04�.nsP of leus�,ov�e lave w11 ��l� 1reJers\]7� 1 ea�l'�c Corc�rol be <br /> �(^�ec�•.u�oc.c� p��( *G 0)144 rua tt Ccrn}1o1 y+s�al�j��� � tped a+1 CouK+ Fi(bAk RoaplS <br /> 1Mot.s�y and i� kt^u1rHo�c. dur �on5, Gc c�e�ouf)ti� o� ` <br /> 3 A vide. t4Pe et 't'Ht PkIr1Atd ka}. rou{c S": aod. )ortsaP'a« l.6 4 CoQ s �ia« �x Yee�.u�ltd. C'o1q/T' <br /> of SZU Jca Cevh-rr Ala, v <br /> lee vie wcd 1w; •(- , Qubl>c ks P/Ior 44 4,-•j• xy s ;&d <br /> The undersigned hereby applies for permission to .excavat , Vo'cn 3.truct and/or <br /> otherwise-encroach on County. Highway Right-of-Way on-the iA&4 i U/66`r sideSof <br /> p vy\g 901 approximately feet/ ile 1Ve2•n•F eF 144M*W9 04n41 <br /> -Of— 75 g NA i t.E Wtr,A n 0A H L-^I' ���n e�by "performing the <br /> following work (description of work) : -lAe.le. A.n6D �eYt� !nlB+AI D2.4in�i4(rE <br /> 40 C, rvt, D t <br /> _BchIQ Re V+A• i t i-47%40— Rk1 ---►rut;r <br /> Work will commence on or about l 2cmo L for approximately <br /> 36 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 approval. <br /> �NtrPJE l • 3(. 0 /0 <br /> 6;Yignature f Applicant Title Date <br /> MASTER.PS\MSCBDL (6/00) - <br />