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1;z/1I/1db/ ey:5ti 10134b813J24 SJCO PERMITS PAGE 01/02 <br /> APPLICA'T'ION FOR ENCROACHMENT PERMIT <br /> PL�,�,,SE _PRINT: <br /> Date 3 v7 -Q OSSICE USE ONLY <br /> To: San Joaquin County JOB # "�7S0 REF # <br /> (Department of Public Works AL:X CR # <br /> Py C � ,Z.�/C,r� I 1�re EX V. DATE <br /> / VALID 1'-4-D8 TO DRIVEWAYS: <br /> 7 (Applicant Name) STREET ��(o 1 'EGcErv�/� SF', <br /> 3 6 �, AREA t 2)A T !d �r <br /> W! L h TYPE <br /> J(mailing Address) FORMS Ly ' <br /> �"`!MC„`�" C���� �Gi C�j•%� NOTE <br /> (City, State, Zip Code) <br /> 9ZS- y741- `-1330 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plane may be submitted) <br /> cv <br /> M, ?'75'/40- <br /> r <br /> The undersigned hereby applies 'for parmiesion to excavate, construct acid/or <br /> other ism encroach on County Highway Right-of-Way on the sido of <br /> M C-9I n1 e S approximately feet/mile <br /> °£ f , by ,performing the . <br /> £ Mowing work ' (description. of work) : i c, 6l s <br /> C4 11t5-f'Sei'7 '- 10 f <br /> Work will commence on or about for approximately <br /> 3 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 /> KhaT9X.[B\FEBBCXDL f6/001 <br />