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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASES SPRINT <br /> Date fig / 4' / OFFICE USE ONLY <br /> To: San Joaquin County JOB # / J�7 7 3 REF # <br /> Department of Public Works APN CR' # <br /> 47-EXP. DATE <br /> !!! VALID d TO 9-/-,o 7 DRIVEWAYS: <br /> j� <br /> (Applicant ,Name) STREET/ 44AIi IA,'A T' <br /> GAREA �EfGQTJ QUAD /Vt- * <br /> TYPE r�TOteE <br /> (Mailing Address!) FORMS <br /> NOTE � <br /> (City, State, Zip Code) <br /> 6-7 4 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 37104S <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> - otherwise encroach on County-Highway -Right-of-Way on the tJ�H *5.rxrfCiside!of <br /> 1 6 on r approximately (1po feet/ i e 'CA-5_f bF <br /> of 1,4. rj���� V, - C RJA by performing the <br /> following work (description of work) : a- LA -A 11 j . <br /> 1C�1n C:5 <br /> Work will commence on or about a 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 /> Signa ur of Applicant - Tia Da e <br /> MASTER.PS\FEESCHDL (6/00) <br />