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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE_PRINT., R E C E(V E D <br /> SAN JOAQUIN COUNTY <br /> Date J1 /Z, - O 2006 SEP 12 1 IM 1: 4 4 OFFICE USE ONLY <br /> To: San Joaquin County DEPT. OF PUBL QrdJOML / a 5O REF # <br /> Department of Public Works APN CR # <br /> EXP. DATZd11 le 62 <br /> E <br /> - Z/►�f w Y VALID /3 d� DRIVEWAYS: <br /> (Applicant Name) STREET ? <br /> AREA <br /> V1_ TYPE o <br /> (Mailing Address) FORMS Sg WW -Z9 <br /> NOTE <br /> oelrb 2 _ 9.55.5 <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plan may be submitted) <br /> tow X00 t�� <br /> �-� 9 w 8 <br /> The undersigned hereby applies for permission to.excavate, construct and/ors <br /> othe ise-encroach on Count Highway Ri ht-of-Wa on-the tide of <br /> - <br /> y g Y 9 y <br /> �1 approximately o� /mile' " <br /> of `" by 'per€orming the <br /> follow' g work idescription of work) : c v �i'soe. y04 em ��! •� S• �s <br /> rr y Z <br /> c,J LhoAm- <br /> Work will commence on or about 57- �z for approximately <br /> I 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 /> 10 re- <br /> Sign ure of Applicant - 'ri� Date <br /> MASTSR.PS\PSBSCSDL (6/00) , <br /> i <br />