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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Y <br /> Date 2 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 230 SET— 3 REF # <br /> Department of Public Works APN CR' # <br /> a T`r„]- •T EXP. DATE r.) ' <br /> !� I VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET VAU"wq 3zD <br /> .1300 F 'iGNT ,�11►1e �� AREA ��Rw QUAD 5E <br /> � <br /> TYPE <br /> i y� '(Mailing Address) FORMS /�.,� --Zq <br /> 0 NOTE — , <br /> (City, State, Zip Code) <br /> tog - TA- 4013 _ <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-Way on the thSt side of <br /> �ur PAV Q� a proximately /SD feet/" j'UC>rrd <br /> of l ti 90 S /I7u r H y IZ bperforming the <br /> following work (description of work) : ?`o2�!'I�f/ /S�� 1rt� 311 JU PZ.14CB <br /> 1e- 06000 E 5 uv'ieE 11)fk& tN 1)&W t]fQM& , 41- ,0X14 1% in <br /> �1►r i ff�Er9 <br /> YC��� 2EF��'c✓tcG [��tCir�c- /o J�,b � X023 �/"7 / <br /> Work will commence on or about 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 /> Si ture f Applicant - Title Date <br /> 6LISTER.PS\FEESQO)L (6/00) <br />