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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date JV-2S- Uo OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7 - REF # <br /> Department of Public Works APN CR' # <br /> r /^� / <br /> EXP. DATE _ S <br /> f�f J J 7-T Ck `44-( &%cco& VALID Z ' TO DRIVEWAYS: <br /> (Applicant Name) STREET edke&2 � W <br /> � AREA 5'-rg l QUAD 25W L 6 IC wf M,LE 9- TYPE � <br /> (Mailing Address) FORMS Z9 <br /> NOTE <br /> (City, State, Zip Code) <br /> !Lg- <br /> (Area Code - Telephone Number) <br /> CJ N <br /> Sketch (Detailed plans may be submitted) �a o D <br /> rt o am <br /> -n s>M <br /> c 7 3 L')M <br /> O Cr' <br /> 12 C C <br /> 70 Q <br /> pc � <br /> L <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-way on the IWILT)4 side of <br /> ola oke& Lo - approximately %zf4 feet/mime 6657 <br /> of & ML TO /22' , WesrD�' u�iLmAATH /Li? by performing the <br /> following work (descri io <br /> tn of work) : 7AMM 1/! f ro T Aead -yozpm &LO-s- _�^��� D <br /> to 5944 cHee okr�2 S. AaJ D Imm.1t 'n 04-T A-8.609 1040M <br /> e I &/a Pr t� <br /> LE45t Q&FE2 6/Lbiie- ?n Sod It S229959 <br /> Work will commence on or about for approximately <br /> S 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 /> AA <br /> Sign ure f Applicant - Title Date <br /> DUSTER.PS\FEESCHOL (6/001 <br />