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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date Aoti1 S 7r�o7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # //00$ REF # <br /> Department of Public Works APN 077- 3 7n -o/ CR' #b�ZC,/S <br /> EXP. DATE <br /> 11 iynrl S )C Ah'--'a VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET auen&e <br /> AREA L&_/c Aavt QUAD L V <br /> 343-1 Ia,,( si e 12-6,o/ JL4 Zoe TYPE , 4.a~- <br /> (Mailing Address) FORMS <br /> NOTE <br /> 52/-7 - /74/ <br /> (City, State, Zip Code) <br /> (Zc�) 9S 7- oCoGo <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) ��zra /a�rKue <br /> N or I'Lt <br /> Lea4 A u e M-1-e 1 <br /> �4� � TPrr��urGry LarrP CGo6uha <br /> Q,y <br /> mice <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the ,Soule side of <br /> /)eadoa- A-wnme approximately O'-8w1fee /mile <br /> of AAALdO, I /hely.,. I , by performing the <br /> following work (description of work) : Z1 '30 e17 r-" <br /> 2 <br /> 7e-mooral-14 Zage MPa n,,, — ge.nue (SO-4 h nv) 6taw 0/ran Aver r <br /> ea4 1jueh&e hoykY, on uht <br /> Work will commence on or about uh a 30 44 2va7 for approximately <br /> `Z , W M 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 t e rules, regulations of San Joaquin County and subject to <br /> inspection and roval. <br /> A0 07 <br /> Signature Applicant - Title Dat <br /> te <br /> MASTER.PS\FEESCHDL (6/00) <br />