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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � OFFICE USE ONLY <br /> To: San Joaquin County JOB # «��U"�' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE A <br /> � ,s royApQhi_ VALID fG-���� TO /� I-� � DRIVEWAYS: <br /> (A p i ant Name) STREET i/UID-lS rZ 41'1-_> <br /> AREA MAO7,,--P, QUAD <br /> 0. Qe'� TYPE ��fi� r.%'� fir"'• �i- !�' =`'- <br /> -I _ (Mai ing Address) / FORMS <br /> 0C.�� 120; CA 11S;2_o j NOTE <br /> (City, State, zip Code) <br /> (209 ) qHb - o302 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plansmaybe submitted) <br /> See <br /> The undersigned hereby applies for permission to excavate,` ccgstru t n`d� r <br /> otherwise encroach on County Highway Right-of-Way oa-t a 4yayicP5 f�a ((�D of <br /> Ntv% ace 2A Ni,V0.+W.y <br /> �ap�.r,,�o�ximately � 44e /mile _Klyy+ <br /> of I�t1 i iow �C�, b erform.ng the <br /> following work idescription of work) Sk0. Iti v u e S��►+'` <br /> ('ew2y' a C o VX r <br /> 7 <br /> —1 r A Y 1=/cl- C' u� G t. ;iCrPJ Z 1041/ I,-) <br /> Work will commence on or about IA Ow a0 for approximately <br /> I11\b"V1V1$ 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 /> �ONA-trn LDS� <br /> ignature of Applicant - 'Citle [Date T <br /> HASTEA.PS\PEESCBDL (6/OC') <br />