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APPLI(_ATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # 3 RBF <br /> Department of Public Works APN CR ## <br /> ! rr ? <br /> - EXD DATE <br /> I _ /TlO(S�(J� <br /> --o- <br /> Applican ame STREET E -744-744--v <br /> 92 <br /> ) <br /> AREA E � QUAD EM <br /> (Mailing Address) FORMS <br /> ( <br /> STdCA ON) lo- D:R�V89�1-►-Yg�=^- <br /> - - <br /> C/q a Q NOTE <br /> �p(City, dtate, iip Code) <br /> (Area Code - Telephone Number) TREY' L,-_- -- _ , _• <br /> Sketch (Detailed plans may be submitted) - - <br /> S A7'D aDuJG, . • , <br /> The undersigned hereby applies for permission to excavates construct :and/or <br /> Otherwise encroach on County Highway Right-of-way on the _ NOQ!K= side •of <br /> approximately ---;20-9-0 ' feet/mile ;.= AT 7- <br /> of-,_ Ac K`TQIv P, Q ) <br /> following work -(description of work) : fll�r��A� �'x ' by Performing the <br /> _PLA,cF A A <br /> CA n Fd 42 - QIT Alwt <br /> —?"HC �1G7i � /�jha,s /�1/ / L4lTR <br /> clrZ1L ! ir, <br /> - e ,b• <br /> Work will commence on <br /> days. <br /> for approximately <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 /> Signa re Applicant - Title G _ -13 _0 <br /> Date <br /> KUTZR-MYRICSOML (6/00) - - <br />