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APPLICATION FOR ENCROACHM= PERMIT <br /> PLEASE PRINT• <br /> Date - 6 3 ' C�c P OFFICE USE ONLY <br /> To : San Joaquin County JOB # 7.362 q' 3 REF # <br /> Department of Public Works APN I # <br /> C L L D[KI��1 EXP. DAT O7 <br /> VALID g! U O I (G DRIVEWAYS-:• - <br /> (Applicant Name) STREF'T' W 44AIAz- 141,111D. <br /> _ AREA , QUAD :.[/ _ <br /> MILE Q[) TYPE S <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 2 o q 44 1)4 - �t ®_3 i <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> F)L(tAS FL 9rLcL S (Grp GI CZ� <br /> -7 <br /> The undersigned hereby pLpplies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the 14 /UOCrMside -of <br /> W, CAat Fal ALV'© approximately 2 CM <br /> .r - feet/mile - <br /> of , by performing the <br /> following work (description of work) : 7(Z,1V P O L r- <br /> -1_IJ 7a A0 Gx -FM& LrAO �to PL/a 6Z C-1br�v n-Pto CAh/,rz <br /> F R drn I-i t C. H V D A Y �;7 70 fiUS l 'li (C (--1 Wn--r e- <br /> bN CNNAL t3LVID, -- SOMCL W �L T'LnC_t 13tTb, OP <br /> C_ary 0v i'T •- QC> r. LA1 i '-YLATL <br /> Work will commence on or about AU- C U_ST I'.T for -approximately <br /> L r-i iJ 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 rulers, regulations of San Joaquin County and subject to <br /> inspection and ppr al, <br /> Signature of AiSilicant Title Date <br /> MAST3R.PS\P88SC°IDL (6/001 <br />