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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> ' " <br /> Date WV, � S 20 0'7 OFFICE USE ONLY <br /> '�c�� <br /> To: San Joaquin County JOB # / ' REF # <br /> Department of Public Works APN CR" # <br /> E <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET e7 A"&q)/ <br /> AREA `3l -c ,/'QUAD <br /> eOZ E G a -AQT,r�f)e 0 TYPE '�- <br /> (Mailing Address) FORMS <br /> 'D�A CC A 9 �D NOTE <br /> (City, State, Zip Code) <br /> ,)(Arg 6 9 , I () S-,)- <br /> (Area <br /> ea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> o A C H G U <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way-on the EAS( - side of <br /> A Ppoa approximately 2 feet/mile <br /> of r"*M"00 , by performing the <br /> following work (description of work) iNSTR�L LANE LdSER <br /> Work will commence on or about SR-TUtOR� NOV, 1-77H for approximately <br /> omc 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 /> Signature of Applicant - Title Date <br /> MASTER.PS\FEBS=L (6/00) <br />