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2Hg46=9324 '-.J,:-_:Cl F'EF;VIT' C12 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASEPR.IM.: <br /> Date __12,o 1 fl, Z007 _ _ OFFICE USE ONLY <br /> To: san Joaquin County k7os # REF <br /> Departme7.t off: Public Works APN CR' dt <br /> EXP. DATE <br /> �1_Gfg S Ct�/y1/1�0!'2t ell A&L F,b� VALTA ;t- -o�I TO -15-07 DRI'V'EWAYS <br /> (Applicant Name) S'TRVI T (A)I DLNDOLfl iZD. <br /> b AREA P_5"40AI QUAD <br /> TYPE — <br /> (Mailing Address) FORMS uvw <br /> rraxE <br /> (City, State, Zip Cod4) <br /> �9 2- <br /> (Area <br /> (Area Code - Telephone Number) <br /> Sketch (netailed. pians may be submitted) <br /> The undersa.gred hereby applies for permission to excavate, construct and/or <br /> otherwise encroach, on, County Highway Right-of-Way on the Nofc lh P Sevm side of <br /> __1/llila��UDud / add_ approximately feet/mile <br /> by performing the <br /> following work (description of work) : <br /> Work will commence on or about for approximately <br /> l'P D <br /> days. <br /> I, the undersigned, cert:.fy that I an, the owner of the respective property, or am <br /> qualifWed to represent the ovmer and agree 1-0 do the work described above in <br /> accordance with the rvles, regulations of San Jeaqua.n, cou*ity and subject to <br /> iaspectio,n and approval, <br /> 07 <br /> Signa re o A pl cant - Title Date <br /> NAITC11. P5�,FEz6CRDS f<;Edi <br />