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APPLICATION FOR ENCROACM4EXT PERMIT <br /> PLEASE PRINT: <br /> Date `'/- <br /> OFFICE USE ONLY <br /> To : San Joaquin County JOB #_7�6 i - 3 REF # <br /> Department of Public Works APN <br /> CR` # <br /> Exp. DAT$ <br /> -t--•f-'�L®--� ,p�.,��`°�� VALID 8-1-0`] TO q /�07 <br /> (Applicant Name) STREET 141PI-UAY �eD DRIV89vAY8: <br /> 2.s t `f- b�!t[ AREA - Qom, sw * --- <br /> TYPE 1�nzkrE Pia C.�B/ 7' <br /> (Mailing ]Address) F0W. <br /> - <br /> 19's-2- D NOTE <br /> �C:kty, S at�o{,- Zip Code) <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plana may be submitted) <br /> � cn <br /> D <br /> e� N <br /> _ Cz" <br /> C; r <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise 4—rCr on County Highway Right-of-Way the Nh(L side o <br /> ofLihL4 'L approximately 1 O' feet/mile - l <br /> €olwing work (description work) ; C- `N erformin t <br /> 1 lel Sl�l.��p -T- � x ' !c�� �p N e. <br /> Ch <br /> N IT4-F t A� • Ow, � � 4 <br /> � � !�v �� <br /> Pr � <br /> work will commence on or about -- l - <br /> days. for approximately <br /> r, 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, regulatioe <br /> 'inspection and approval. of sen Joaquin County and subject to <br /> Sign t e of ]AvDlicaat - Titlr —2-7 �D ` <br /> Date <br />