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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1I /0-7 OFFICE USE ONLY <br /> To: San Joaquin County JOB #�magr� REF # <br /> Department of Public Works APN CR # <br /> �f��,�^ EXP. DATE <br /> �9 T �' '� 1`�' (24 AAIT-E' VALID -off TO DRIVEWAYS: <br /> (Applicant Name) STREET eA1J0,1. &,VI) <br /> r,- / D^ AREA i"tel C I QUAD <br /> 230 �• CST�i�V� ISL/ • TYPE r46A C_ 4j krC <br /> (Mailing Address) FORMS <br /> W1 VNI, nA q5240 <br /> NOTE <br /> (City, State, Zip Code) <br /> C?.8q 47 Ci '42y7 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate; qonLqtract 'and/or <br /> otherwise encroach-on County -Highway -Right-of=Way on tie - side -of <br /> t.V approximately '� n 44 fe /mile <br /> of byerforming the <br /> following work (description of work) : W <br /> k W <br /> Work will- commence on or about H 116 /o-7 for approximately <br /> y 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 ature of Applic t - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />