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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date ^ <br /> a — 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 11-065 REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE loll&LOT <br /> VALID O TO 1014101 DRIVEWAYS: <br /> 'r/lprn /1 f (Applicant Name) <br /> / STREET l,i ►ro�5 .Sf► <br /> / AREA ary QUAD 1641 <br /> SG -71 b4,). f�I�') ah 0 4 TYPE �GAyp sc./ lisurc <br /> (Mailing ddress) FORMS ccs <br /> / NOTE <br /> L-� y c/%, fid 9-So? y 0,z <br /> (City, State, Zip Code) <br /> '4/7 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> F-o r CC- e—L./e-n <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/mile <br /> of by perfo�(Jming the <br /> following work (description of work) : �rA-L�r lC d ��vS�K o 1-r4M+' Eu /�✓"'�,� <br /> ue. Y Lr o r31o7 <br /> ' �� ,K • O ;oo.?an 2;oo�m <br /> Work will commence on or about 1014rLo 7 for approximately <br /> z 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 /> 011 cP1 <br /> Signatur f Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />