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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLUS E `PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County. JOB # Ilaa 5' REF # <br /> Department of Public_ Works APN CR # <br /> EXP. DATE d O{� <br /> Q �7 t J Gi. C��� VALID Z TO M4 e DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA Ll ,V QUAD <br /> TYPE PRe <br /> (Mailing Addrase) FORMS <br /> NOTE <br /> ® - ` cp <br /> (City, State, Zip Code) <br /> (Area Code Telephone Number). <br /> Sketch (Detailed plans may be submitted)' <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach' on County Highway Right-of-Wary- the e_As 4 - nide.--of: <br /> y i.�>y � lr�l�\l •3 <br /> approximately D 05feet/mile. 00K 1 <br /> of L P <br /> li -2E *,?—A by pef orm:i.ng the <br /> following work (description of:work) <br /> Work will .commence on or'about CP for approximately <br /> 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 /> Signature of Applicant Title Date <br /> KkSTBR.FS\Fn CBDL (6/00) <br /> i <br />