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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLBASE PRINT: <br /> Date 3Z;�L10 7 ^ � OFFICE USE ONLY <br /> To: San Joaquin County JOB # �dD'� gEp # <br /> Department of Public works APN CR # <br /> C4 4 UP. DATE � � <br /> _. / __ VALID - -D TO ID DRIVEWAYNi <br /> (Applicant Name) STREET JOU-_ <br /> EA S�e7D L/Q'UAU �' w <br /> I _. r S I�fir 11110ht YYPE <br /> (Mailing Addrams) FORMS <br /> 7-y c -rc tJ CA <br /> NATE <br /> (City, State, Zip Code) it <br /> 26 737- 8 - 43 <br /> (Area. Code -. Talephone Eut*or) <br /> Sketch (Detailed plans may be submitted) Flans {�}�,{� !�J v t Vtin <br /> w ll 1'hS�ull <br /> 1' b s y <br /> a Y tar, %K)"h -,Nap <br /> I Li <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> of rw.iee encr ach on County Highway Right-of-way on the _f, k , slide of <br /> approximately feet/mile <br /> of y eYfo frig t as <br /> fo] o work (description of wcrk) : <br /> CA-.L <br /> Work will commence on, or about aM rN 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 /> acro 'ca <br /> with the rules, regulations of San Joaquin County and subject to <br /> in -c ori and approval. <br /> ignattur of Applicant - tle atel <br /> M,4&•raa.ne\eBl6CH17L (6100) <br /> Td Wd8S:ve z80E ZB TBV8 L26 60E: 'ON Xdd S71dm 0I-19nd NOIA0xiS d0 Ai I o: wod j <br />