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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date ©VZ-1 © �7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public, Works APN CR # <br /> � �o�/� EXP. DATE '7 '07 _Qona(-d EoM eriSe- VALID 6,45'-J-7 TO 7- —d'7 DRIVEWAYS: <br /> (Applicant Name) STREET -r-CEV8 l-b <br /> --7q3 <br /> 7 2 AREA -M4kc.y' QUAD �Lj <br /> r q J C V D TYPE � <br /> (Mailing A ess) FORMS <br /> NOTE <br /> �Ct <br /> pity, State, Zip Code) <br /> (Area Cod - Telephone Number) <br /> �� tldJrc,s' <br /> Sketch (Detailed plans may be submitted) <br /> (See `-,'a-A C_4C-d 1 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-way on t ', sid of <br /> 'Re-Lie *AJ approximately feet mile <br /> of /,Ae� by performing the <br /> following work (description of work) Esc,,,:,fe Fre., ve,? , wct�.s e7xi5*,,4 j r;Ve. -.$ <br /> fQ Aloe+ti 5,'.Je iyL fv �J(gr,a Cc zl✓ t W1nP,, !'vm�PcsfP Y�ScfcF �l d >n..{ch �Xisf.�3 rlc'✓r <br /> l0'7 �G ?,QErtGN Jit/ ZNAC ,' <br /> Work will commence on or about 041L2-z,/p'7 for approximately <br /> Z 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 /> Signa tu�of Applicant •- Title Date <br /> NASTER.PS\FEESCHDL (6/00) <br />