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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f IAS OFFICE USE ONLY <br /> To: San Joaquin County JOB # �jU/7- REF # <br /> Department of ublic Works APN CR # <br /> EXP. DATE <br /> / - � ,✓�i.�/-cam VALID -14 D TO DRIVEWAYS: <br /> (Applicant Name) STREET A'51"G7L# e?4-45 , <br /> AREA -7Z.-4 c V QUAD :540 <br /> J C�(7 fig.% �`i( TYPE <br /> * <br /> (Mailing Address) FORMS. <br /> NOTE <br /> (City, State, Zip uouel <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) o <br /> � N � <br /> o 2 <br /> < >i <br /> 7g Cn <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> - otherwise encroach on County Highway Right-of-Way on the SO4'Til side of <br /> 4pC approximate^l,�'_ -2- 60 feet/mile I-JC5>" <br /> of / i42A,�iJ� Avg %7c�f, e_s4I by performing the <br /> following/work (description of work) : 1-?" 7- jai [� oS <br /> C���ST/�-G �y�/L�•Ei.> �EL t'/�/�C1�t �4i3G'_ /�( �' "`"` � f�/F 4�/,r� /�CUi Ty <br /> %u' /�/ZJ�iiy� i6�i`7t 7*�r cSt2��Cc f ' .✓G'-0.3 F�cs T = �T 4 16 3 Kfuc <br /> Work will commence on or about tel` /`/ t for approximately <br /> t3© <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 /> 02 ��v <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />