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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date r�W 0 7 <br /> FAPN <br /> FFICE USE ONLY <br /> To: San Joaquin County Og _ REF # <br /> Department of Public Works Z� -}S CR' # ►�i�/ /�0-07 TO 1�-/-off DRIVEWAYS: <br /> (Applicant Name) fj125f� < <br /> / QUADl y" <br /> (Mailing Address) FORMS 55 ,wja, ,4,1' Z-' <br /> y <br /> qfzr NOTE —� <br /> (City, State, Zip Code) <br /> Z � <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> tib,{n/�1✓' 'C ha�o . <br /> �dCt„w� lWefes <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the lV220, r-f{ <br /> 5_;r7 approximately of - <br /> of _i0.te,?n V aPProximately FSCs <br /> A14-457- <br /> -r y�e/aZ A) by performing the <br /> following lwork (description of work) <br /> LI yv1,-4ib'T C.Di CL ,- Nti:� � 41 l.` e I iGl <br /> /�4 l f 1 Aie I <br /> Work will commence on or about <br /> for approximatel <br /> days. y <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 V <br /> Date <br /> MASTER.PS\FEESCHDL (6/00) <br />