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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> CZ 7 116 7 OFFICE USE ONLY <br /> To: San Joaqui? -_cunt,, u0B �flJi�J REF <br /> Department of Pub-i__c Works APN CR' <br /> EXP. DATE <br /> A }rc� IyM VALID TO DRIVEWAYS: <br /> WAter .yA1' (Applicant Name) STREET 6G. jeq&3r_k-o <br /> C04strut110,1 orfict. AREA-TV*Ctt QUAD 5-�k) <br /> AS77 .Slow,^ Cour-F -Su&L t� TYPE PdRn C405"AS w <br /> (Mailing Address) FORMS ---— <br /> NOTE <br /> Trac CA �53ay <br /> ( ity, State, Zip Code) <br /> 2041 2zi - 6sg4 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> lwws .S•,1•w+,�tt�r� w rl%, APP l 6w.-1..+ . <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the V4+91%t PDad mi!6 of <br /> FL Ranatio Ao-J approximately 7_00 feet mile e"k %iA4 <br /> of 0?.ou+p- 20S / EL QA&Ao 2e..a� L�i�erid� Worth and soulk by performing the <br /> following work (description of work) : r 1 s 'rilots <br /> u--d I`t•hswe ;1de;✓� L'01"- ion oF tbly'"As Co OIL / <br /> K"Qw�1 %oG <br /> o A" To 3s5a P. <br /> Work will commence on or about duaa_ /�� 200 for approximately <br /> 2S wp�k�%a; <br /> days . <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified tc represent the owner and agree to do the work described hove in <br /> accordance with the rales, regulations of San Joaqui.. County and subject tc <br /> inspection and approval . <br /> Signaturetof Applicant Title D _e <br />