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APPLICATION FOR 9NCROACHURNT FERMI' <br /> Date q/5 Xo_ DROxCE tism ONLY <br /> Tot San Joaquin Co=ty L701B # 11005" RAF # <br /> Department of Public Works APN <br /> EXP. DATE �p-iS-al <br /> VAt= oU•I-U1 TO 10-15-•01 DR�VEWAX9: <br /> (Applicant Name) STREET V8CIOUS RDS <br /> ,AREA STdckT"rJ QV,A,D _L"� <br /> TYPV, 7gAFi'c'ic_ GourQoi. 5)e <br /> (Mailing AdArmss) FORMS <br /> t� NOTE <br /> (city, State, 2 p code) <br /> qZ <br /> (Area Code Telephone Number) � . <br /> Sketch (Detailed plans may be submitted) m <br /> --o <br /> Post-RO Fax Note 7671FFrorn <br /> fIt of <br /> 7 p <br /> Tv /'C!J dd / <br /> Co. 77 <br /> Co./Dept. GJ <br /> phone 4f Phonc# O <br /> Fgx (1P5���Fa-Gb83^ <br /> Fax <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Plighway Right-of-Way on theside of <br /> approximately � feet/mile <br /> by -performing the <br /> fo11lowing ork (descrip;tion TE work) <br /> v <br /> Work will, commence on or about c ��� � , ��� for approximately <br /> days <br /> 1, the undersigned certify that Z 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 Applicarit - Title <br /> Date <br /> fMs2sR.o.S�FHR3r,H'DI (6lOoY <br />