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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f -7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # /l(>OS REF # <br /> Department of Public: Works APN CR" # <br /> �oC- a EXP. DATE -I6-5`7 <br /> C(5AJ57_A1-C1' !i/Od VALID -7-1 7o 7-ISy7 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> e�,eAyy * <br /> SEA �_ S2UAD <br /> (Mailing Address) FORMS M — <br /> _ NOTE <br /> (City, State, Zip Code) ` <br /> `� 156 - 6 ul 2, r'? g <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> O SS <br /> 1983 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> PEI-31ET AVF-- approximately 275' fe mile :5ourY <br /> of , by performin the <br /> following work (description of work) : Gl-loV,'7 A/r r2Ej.A C <br /> 01 14.sPu✓a LT 22 /r✓ST✓-11-4 ice.! a-�eQ 1_ <br /> Work will commence on or about 7 4 49 for approximately <br /> 15- 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 /> Signature of Applicant -• Title ! Date <br /> MASTER.PS\FEESC}DL (6/00) <br />