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i <br /> APPLICATION FOR ENCROACHMENT PERMIT RECE' <br /> A A ?04tltli �0 N7 <br /> PLEASE PRINT: 06 JUN <br /> 5 <br /> Date �,� �© _ oSSG� °�Vt .IIl1 PUBLJC WORKS <br /> JOB REF <br /> To: San Joaquin County A_pN CR: 4 <br /> Department of Puhlic Works Exp DATE /O-�s DING <br /> VALID 7� 2 TO /O�/��4! DRIVEWAYS: <br /> STREET ,��'sN� — <br /> (Aprp-lica EA e,16A414)-M QUAD / <br /> PE <br /> (Mailing Address) ORMS wOTE <br /> ��Gk�ic� c�� So2D 1 <br /> (City, State, Zip Code) � <br /> (Area Code - Telephone Numb <br /> Sketch (Detailed plans may be submitted) <br /> F 7�'_7 X/ i <br /> L <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> side of <br /> otherwise encroach on County Highway Right-of-Way on the ee mile <br /> approximately am /i C, by performing the <br /> of q-i�66,1 rV <br /> following work_ (description of work) : r , ` I f2% <br /> 6, ZY4 /711C <br /> �- <br /> for approximately <br /> Work will commence on or about <br /> O <br /> 9 o days <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> dothe <br /> qualified to represer.(t the owner and agree to Joaquin County <br /> en <br /> and subject to <br /> accordance with the rules, regulations of San Joau Y <br /> inspection and approval. <br /> � '�r (7 CI S5�'iJylG7 <br /> Date <br /> f _ lica::t - Titles RETURN <br /> sigr�a�.u= � n„r� PERMITS T0: <br /> MASTER.PS\FEES=L (6/00) �w w�--- <br /> a.lr.F�`�/404 M D <br /> m ' BLD 1 <br /> CA 9=4 <br />