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1 .. �• 0 v <br /> APPLICATION FOR ENCROACAMET PERMIT 8,14%// <br /> PLEASE PRINT: <br /> Date _ -_ S=Z 2 , .0 -3 3 OE 'ICF. USE ONLY v <br /> To: &1n Joaquin County ,; " -"'' JOB' # � �- REF # <br /> Department of. Ohl}c, Works APN, <br /> 1 <br /> EXP.- DATE 1 <br /> Col1;CPP o�y% ci Ve,4e./ S�rV�Gf. VALID b_ TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> tt I AREA3" �QUAD <br /> u r r.,o h-�' S t• H I O O TYPE S * _— <br /> (Mailing Address) FORMSbt�,�-Z <br /> NOTE <br /> (City, State, Zip Code) - <br /> 209 - tyo <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ST E <br /> == -rn <br /> _< <br /> C <br /> 3" N <br /> O <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the 67- side of <br /> I N L E y approximately S ZD 7 <br /> feet ile _ Al 0P-7`� <br /> or ,N busTi(wL I>V-' , y performing the <br /> following work (description of work) : ZN.ST G//Vk�a <br /> �/ �� 5£1ty <br /> /n&TvE/R '/303 S /ted6y Atvif <br /> c-r z 0 a 0 bO g 7'7 <br /> HT1 V-vr- =p 34-T - <br /> work will commence on or about Z for approximately <br /> 9 0 days. <br /> I, the tLndersigned 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 /> Signature of Applicant - Title Date <br /> MASTU.P3\P68S®L (6/00) <br />