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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date '10S - r v - o �Z OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT / O <br /> T«0 tz 1-i �-o`J F-:c(7_-e- (D z s l VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET 1l'd$t <br /> AREA 7�Y4A4,-)Z Q QUAD /SCL <br /> U 13 TYPE Oc`.�-s;r AO <br /> (Mailing Address) FORMS <br /> NOTE <br /> 0r GF `IS G 6G <br /> (City, State, Zip Code) <br /> 2-6- - fo - %o 5 .7 cHF F <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 3 iN'i C--(-LS GcT _c r j -Q <br /> T_,A i2 ry s'� 2 �2 l7. f °r'He cZ N <br /> 3, ( R N <br /> The undersigned hereby applies for permission to :excavate, const uct and/or <br /> otherwise-encroach on County Highway Right-of-Way.-on-the N ;-2:r(4 S opt hf side_-of <br /> IL T'-iroximatelya /mile <br /> of P_(2 i.-r 7C-- Z .�, �N t,�r U- itw i-� �Z iV�c CZ , by "performing the <br /> following work (description of work) : <br /> T1"i t2 JN;� �v �rCZ-F_rLC- (-1 G- (zS o 'V <br /> Work will commence on or about O S \ � " for approximately <br /> 1 U 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 appr al. <br /> cllfC7 r4 <br /> gna re lic nt - Title (=��z F �-rS Date <br /> AS5 «' <br /> MASTER.PS\FBES®L (6/00) <br /> C p.ry c)N 1 -7 140 N t= IS- -7 9 •� - Z °1 6 U <br /> i <br />