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/ APPLICATION FOR ENCROACffi�iENT pggZT <br /> I <br /> LEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> OB 11717D <br /> B�07 <br /> REF <br /> 33 <br /> of Public Works APNATE <br /> (Applicant Name) —9l&41v�— TO . ## <br /> . DRIVEWAYS: <br /> .... <br /> STREET _ l&ia 4ue <br /> AREA s42cillth" QUAD 6-5___- <br /> TYPE _�C►lGh <br /> `� (Mailing Address) <br /> � ry <br /> FORMS 5s w w 2-Z9 <br /> S-bozXt0 C lv CX� S NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Ci <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach•on County-Highway Right-of-Way•oa•the � <br /> LL: FO Pt`o1 approximately 671' ' - <br /> Of ee a side;.•of .. . .. <br /> �Z ��S FiV <br /> following work (description of work) :, by Performing the <br /> -- <br /> ��VLJ� X fKI11 5 tc <br /> C1�\PR�O�, <br /> \__eLL\N% N®oF <br /> Work will commence on or about Q-� ®� �� 3MIlt <br /> days. for approximately <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, regulat'ons 'of San Joa <br /> inspection and approval ,Q� Q$-p"d gain County and subject to <br /> Signature of Applicant - 'Title <br /> Date <br /> MAST8R.AS\FHSS®L (6/00) <br /> i <br />