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L4/ ZUYJ! 1!.tj LCI D400 uJG4 JJI�V rGRI'11 I J rlul- UL/ CJL <br /> APPLICATION FOR ENCROACSMNT PERMIT <br /> PLE PRINT: <br /> � ��� <br /> Date ZOFFICE USE ONLY <br /> To- San Joaquin County JOB # 73052-2,0 REF # <br /> nepartmen.t of Public Works .A.py CR # <br /> ERCP. DATE '- �7 <br /> � 7 �i 1 ) r eine VALID 8^4"�7 TO F-/--67 DRIVEWAYS: <br /> (Applicant. Name) STREET Z/41W.Ct'Se'VAW �• <br /> ?,e x <br /> L� � TYPE QUAD <br /> 1575— <br /> /f,y �: -� �S� TYPE <br /> (Mailing Addra0a) FORMS <br /> NOTE <br /> (city, <br /> State, <br /> zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> /,,)//v 3 2— <br /> Pn�l -7v5577¢28 <br /> The undersigned hereby applies for permission to excavate, cor��tr et and/ox <br /> otherwise encroach on. County Highway Right-of-Way on the cc��// aide of <br /> approximately 3c feet/mile <br /> of N�cJ� r3� 'performing the <br /> following work (description of work) : �•�� �'��� .�.7 � d<�'' <br /> - <br /> Work will commence on or about C3 for approximately <br /> days . <br /> I, tb,E 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 /> ins ectio d approval. <br /> c <br /> 7- <br /> Signature of pplicant Title Daze <br /> MAST@R,rB\F9BFCf0L <br />