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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 7-17-e,6 OFFICE USE ONLY <br /> To: San Joaquin County JOB # /r�DU REF # <br /> Department of Public Works APN CR # <br /> L EXP. DAT / 06 <br /> �r>✓�r.+,�•S �t �p.�j•�irr. /�Owl�wtr VALID 7 06 TO DRIVEWAYS: <br /> (Applicant acne) STREET ism <br /> '9137 <br /> AREA ��JI/lL�J✓ QUAD <br /> 7137 4,ii.n C T TYPE�LG�f�UlE f�I� <br /> (Mailing Address) FORMS <br /> NOTE <br /> Sfi���o►n LIf QsziZ <br /> (City, State, Zip Code) <br /> Z01 y'3l- ,/-V <br /> (Area Code - Telephone Number) <br /> fl � <br /> Sketch (Detailed plans may be submitted) m r_1 D� <br /> -v Z <br /> --� <br /> a <br /> C)71 <br /> r- >ri <br /> Q o <br /> C �C3 G <br /> O <br /> o a <br /> = w -4 <br /> 7K "' -< <br /> to <br /> The undersigned hereby applies for permission to excavate, construct a�}d/or <br /> otherwise encroach on County Highway Right-of-Way on the _S.-Ay�w side of <br /> !`� <br /> R,jfp approximately 3130 01 feet/mile La/r1' <br /> of by performing the <br /> following "Vork (description of work) : <br /> .Cx;STH 4-47"✓ .e- ♦!/ <br /> y Ch1fM rr 8 T1r/ LIITV Vrv�f %r+ ✓ •+ firs fist <br /> ✓twt y Ij r r SS v 04'✓ 92tf_ ZZAI/ /to <br /> C� Vn✓WT •Iwo t Cor►�ir /1 � /�j w..�. ""C'. <br /> Work will commence on or about 7'Zd"o6 for approximately <br /> 7 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 rule;, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> _ <br /> 2ey-`Vf-7/8� <br /> Si ure of Applicant - Title Date <br /> TER.PS\FEESCHDL (6/00) <br />