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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 4 Z s- OFFICE USE ONLY <br /> To: San Joaquin County JOB # WO 3 REF # <br /> Department o'f1 'Public Works APN CR" # <br /> A T7 7o T (�/CS�oh <br /> EXP. DATE <br /> VALID 'JPO DRIVEWAYS: <br /> (Applicant Name) STREET Crs.TCVS 73uR� <br /> 2300 E g /+li/t 2� AREA STo�-K+Tow, QUAD !-.W <br /> TYPE J kEff, <br /> I (Mailing Address) FORMS _�,Tml <br /> s of k�nn 6,4 r!Sz/O NOTE _ <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A7"r ye <br /> A T T 7o -P X d3 A viv D C.�l, � vn at X X f, S Cont✓ef�1P,�L• <br /> PlAze Aix o ' as Ra A <br /> i,fOpe, 461 -A4;r) 49 .wjq,;S koX -vzZ ATT wW <br /> G�4,4,'S as f�am aH c�.n./i s -(, 6, y <br /> go- 0, �Cllce. <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> - otherwise jencroach on County Highway--Right-of-Way on the - �✓�s side -of / <br /> lic Ins!!f - approximately g`/ FT' feet/mile 5'«.ry <br /> of L�eoto by performing the <br /> following work (description of work) e� �'�'�" �►� ir�� alc�r.C4li✓�SJI <br /> Work will commence on or about for approximately <br /> day . <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 /> ZS"-off <br /> Signature of A licant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />