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APPLICATION FOR ENCROACHMENT PERMIT <br /> vr,,SASE PRINT• � � � . <br /> Date ® ® _ OFFICS USS ONLY <br /> To: San Joaquin County JOB # 73u7 REF <br /> Department of Public Works APN # <br /> nn pp \ �r CC pp c Q\I <br /> "XP. DATE IZ-15-01 <br /> VALID 10-10-o-1 TO DRIVEWAYS: <br /> \. �(QApplica�nt�Name) .}� �*� STREET •• 5?- <br /> 5s0 `�`JL 1\��d 1V 1 � �'C'\W AREA SToGkTdi✓ QUAD S� * <br /> TYPE _P."yEr_> <br /> \` (Mailing Addresss)� FORMS f—,e�, <br /> 910 3 NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County. Highway Right-of-Way-•on the " sidps.af <br /> approximately <br /> of _ // by -pe-rforming the <br /> following work (description of work) : VR=XT M v 57�l low - <br /> 0111\ &-'N x 14 a I VVVs <br /> a'A wa S � S7 -vo�wL sxn'-' RFx_K "N=' <br /> Work will commence on or about for approximately <br /> Yv <br /> 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 rule regulations 'of San Joaquin County and subject to <br /> inspection and <br /> M X\)\hzAA tz - V® Cq `CJ7 <br /> Signature of Applicant - Title Date <br /> MAST%3L.PS\P83S®L (6/46} <br />