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rr-lulI •l"L-IFUMIN1" W"1C([ JCENv1 _ rnn 11V. .GUJ 1V•Y- r1 • v- -- -+. <br /> APPLICATION FOR ENCROACMMT PERMIT <br /> pLEASR PRX T: <br /> 'R�pate OFFICE USE OMY <br /> To: saa Joaquin County am # :2307-7_ REP # <br /> Department off Public Works AD14 CR # <br /> VAID <br /> X, TO DYtXVWAYS: <br /> (Appliicaut Name) STUET + <br /> AREA QUAD A15 <br /> TYPE 1G <br /> y s_ (Mailing Address) FORMS S <br /> \�\ Z�� '� z d NOTE <br /> �(�G\]3�tW, S t a1ta�, ,Zyi..ypCode) <br /> I - I <br /> (Asea Code, , Telephone Number). <br /> Sketch (Detailed plans May be submitted) <br /> M <br /> o a D <br /> o �- <br /> `v 0,;0 7:0 nn; <br /> � <br /> • cxr C <br /> r 77 <br /> V� �( <br /> The undersigned hereby.applies for permission to.excavate,' const not and/or <br /> otherwioe•on roac on County-Irighway Right-of--Way•on•�$o o'de,•p$ , <br /> approximately ee �� <br /> of , • • by- orforming the <br /> followingw9k (description of work) - <br /> Work will comm&ce on or•ebout for approximately <br /> days. <br /> I, the undersigned certify that X ant the owner of the respective property, or am <br /> qualified to represent the owner axed agree to do the'work described above in <br /> accordance with the rules, xegulat- of Saxe Joaquin County and subject to <br /> inspection and approval 14 e�-•p� . ' • <br /> y � •a�� o� -off <br /> S19X%Ature of Aplslicaut - tie Date <br />