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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J n 12- 2—LJ Cf OFFICE USE ONLY <br /> To: San Joaquin County JOB # eo `3 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> l L Z, 1 U L� i VALID 7-i5-a7 TO 07 DRIVEWAYS: <br /> (Applicant Name) STREET rlq� Ldp L <br /> AREA :5rCC,4 7'L UAD _ <br /> TYPE 9006 "T <br /> (Mailing Address) FORMS « 'L <br /> J .) -� NOTE <br /> 7-Cti' �q lS� /1 �' <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The <br /> applies for permission to excavate; construct 'and/or <br /> - ot$e widsese�ncroachigned ronyCount -Highway Right-of=Way on the �� side of <br /> t_V CT approximately �mile Zig S % <br /> of �� by performing the <br /> follow�ng work (description of work) : LCx LL'L% /3LVd 301,0 bill 'C u, Si 112�E_ <br /> u riT 7_i2 Cil? h �iZa,� �%T �v E,/isr <br /> f e77- 3LI"X /-1-61'X fier c,-; y 1, 1/ 110 <br /> Work will commence on or about 1-WS/f/) - UGI for approximately <br /> 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 /> J J <br /> Signature of Applicit - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />