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VV/ Ll/ LCJVf 1J.YJ LU7YVV=7JLY JJI.IJ fGl�l"Il IJ rHl]C Gl/ to <br /> ^�., <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRIN'x <br /> Date OVVTCM USM ONLY <br /> Jon #^ RAF # <br /> TO: San Joaquin County APN ' '� CR <br /> Department of Public Works <br /> EXP. <br /> DATE � � <br /> S�I,J LI-6J ' VALID 7 "d-) TO DRIVEWAYS <br /> (Appl�.aan,b Name) <br /> STREET ZUAI/it/14LT +�. <br /> C4 0 TYPE RSA �_xy1CC QUAD <br /> Y (Mailing Address) FORME 'Z <br /> S `7 NOx'E <br /> (City, State, 7,jp Code) <br /> 2- cPi -- M� ,- Ll L r I q <br /> (Asea. Code -. Te7.ephone Number) <br /> sketch (Detailed plans may be submitted) ) � n <br /> vs 1 U� iS `s`a <br /> >Jy<,4 ' 1 , ,v , <br /> I C� fi � <br /> The undersigned hereby applies for permission to excavate, cons t� uct and/or <br /> otherwise encroap} qn County Highway Rxght-of-way on th-a q ff �At� <br /> �uy✓i���d^4._ i t,_ annroximately deet mlle <br /> y 'performing the <br /> following work ('description of work) : <br /> 410 'a 4 zqs <br /> Woa:k will commence on or about CQ for appzoximatel.y <br /> days. <br /> I, the undero igned certify that I am the ovmdr of the respective property, or am <br /> qualified to repreeent 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 /> ins-o t .on and approval. <br /> 9 hat of Applicant - Titlee Date <br /> htA82'kR.e8\7EE9CND7.. (6/00) <br />