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APPL,IC kTION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> D,ate 4 -?-1 -oma JOB # fi ADS REFH <br /> APiv - - CRVN <br /> To: San Joaquin County Highway Department. EXP. DATE &P 146 <br /> _ VALID / olo O l01'/ DRIVEWAYS: <br /> STREET IF/we . s <br /> (Applicant Name) AREA f.5cAGo+J QUAD <br /> TYPE_ ►� A /!, ,tie # <br /> P.O . t?,oX AqbCc;.o FORMS <br /> (.NLailing Address) NOTE <br /> t,nO A �'- <br /> (City, State Zip Code) LN,Mfg I <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans ma be ;►ubrait'.er:) <br /> ElCtS"R�-16, N►•I.1J. �C�DADS�,D D�{�Lµ�E�D . <br /> Otl�'72N�cU P0V-4dz4'11'4E �Ot�Ei21.1►1�, L��D�51N4 <br /> w-e <br /> M.t.p. ACzA-w�laE�S �` �►¢�a.i Qtr, <br /> El�1GL�S�� A1�n <br /> grd. r5 ZS�tl,ue. <br /> The undersigned hereby applies for permission to excavate, construct and f or otherwise etacroach on County <br /> Highway Right-of-Way on the t1Wot4,-tu side of approximately <br /> 24v feet !fie 4F-L.=- of w pf:6 tC-'R Wks by PedominS the <br /> following work: (description of work): !�s-�c.� 15 a` a F C3� �- �-AGSR t` V4NM�- <br /> CLo t-n P►-� �s� r.n " o AcX:Cr, Sou- A�I�o sS 0. v ER -Tb <br /> c v t t-•t-- <br /> -�LEa1rkT bt= w•p�� <br /> Work wcommence on or about 5 - 15-D� for approximately ? a13'$• <br /> ill <br /> I the undersigned certify that I am the owner of the respective property,or am gnalified to represent the owner and <br /> agree to do the work described above iu:tccorcl--rice with the rules,regulations of Ste.Joaquin County and subject <br /> to inspection and approval, <br /> -- X �� �-`- . �►.t.4 `pct-� ICC SC 4-2-1-ao <br /> SITNATURE OF APPLI t�'vT - =E DATE <br />