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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE -PRINT: <br /> Date r OFFICE USE ONLY <br /> To: San Joaquin Country JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT <br /> °- ti ����"i �' ,i��{r`� VALID 8 /3 0 TO 12.71 DRIVEWAYS: <br /> (Applicant, Name) STREET <br /> AREA 57r'e,&-VA1 QUAD 44-76 <br /> Po TYPE TZ'grdU12 AQae,7Ue 57:A&4/� <br /> (Mailing Address) FORMS .� <br /> NOTE <br /> �AI-141zf)o 4A Lf� -i6 0 <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> " 7 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on Country Highway Right-of-Way on the � - side of <br /> approximately wC' ieet/mile <br /> of 1_)L e44 t46L4-LC)L A� div �h�1 .e?, �'v1 -Y by per€crming the <br /> following work (description of work) : <br /> /A,,,, Pivot ro atiNvl r LJGtiLiNWs- ✓l�;vl ✓'? y? (, �.s,.rU <br /> i ", 4 l�� <br /> l 74 ty' " } tet' b z�!"b!P �T yr ) ✓1 T{9 ,3 rY <br /> .oyo i-'tmv; ;o rhC <br /> Work will commence on or about F) i?� �'1 for approximately <br /> i(-,: 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 /> Signature of Applicant .- Title Date <br /> MASTER.PS\FEESCHDL (6100) <br />