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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ` ` ` ` `� O J VAOFFICE USE ONLY <br /> To: San Joaquin County JOB # REF ## <br /> Department of Public Works APN CR # <br /> EXP. DATE Cv" 5=a7 <br /> C��1 FORt�1R �1�t A LR S�.�V a VALID 4Z 2 TO '2 07 DRIVEWAYS: <br /> .j (Applicant <br /> �-QName) STREET <br /> J\ -\C AREA 57Gc/CTVL/ QUAD A/5 <br /> TYPE "�'cGtJr H�kD <br /> A(Mailing Address) FORMS r Z-/ <br /> lz�s`aO ]�s NOTE <br /> (City, Sttalte, .Ziip Code) <br /> -1,1��` Ck] 1 1 <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> VWT <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County-Highway Right-of-Way••oa•the side,.•of - <br /> approximately feet/mile <br /> of '. " .4 . , b 'per€orming the <br /> following work (description of work) : \�10 � N\C' <br /> CoU�R'Y PRc��.�'•-�'Ns-C'A LL 500� o F 1p�� PVC.._ <br /> C -ZT OFZ w% 'ZRAO �FLQS«C` <br /> NAY RR'N �V F CZo _'1P?1mMC `-M- CSS I%(ZL14 4 <br /> L%4b-IoPP.� <br /> Work will commence on or'about 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 /> accordance with the rules, regulations 'of San Joaquin County and subject to <br /> inspection and approval. <br /> wghKIM-oW_RMQ%s <br /> Signature of Applicant Title Date <br /> M STME.PS\$BSS®L (6/00) <br />