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APPLICATION FOR ENCROACEMENT PERMIT <br /> FLEASE <br /> Date �{ � OFFICE V5E ONLY <br /> To; San Joaquin County Jam# I0OQS'� REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE ZC V' <br /> VALIDf. <br /> .->. . PO aRlvswAYs: <br /> -(!App icant N e)r STREET o 0Y\. 15, <br /> AREA LOd i QUAD <br /> TYPE 1 - 7791✓� <br /> Address) FORMS /J1L4..- <br /> 2F"9 NOTE <br /> (City, State, Zip 'Code) <br /> (Area Code - Telephone Number) <br /> Sketch (]Detailed plana may be submitted) <br /> The unde•reignsd hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County' Highway Right-of-Way on the AigLiIa,. C.:,r- sidE of <br /> � I.J. approximately feet/mile, <br /> of by performing the <br /> following work (description. of work) : ri.v J:'S�7r' • 7"d <br /> A t D R-I ye. <br /> Work will commence on or about 4;> I_1p. c2S i�n.g i< ter'cA:> <br /> -�- �� for approximately <br /> �/ ^_ <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 rules, ragulations of San Joaquin County and subject to <br /> inspection and .approval. <br /> L 3-,a <br /> 06 <br /> gnature of Ap cant - Title Date <br /> Fcr,.•� l7rSj. <br /> ,MA8TFA,PZWUa%9CxDL 16/0V) <br />