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APPLICATION FOR ENCROACHMENT PERMIT <br /> ��+FA3L PRINT <br /> Date �� rGl, G Z C56V OFFICE USE ONLY <br /> To; San Joaquin County �0 # �� _ REF # <br /> Department of Public Works APN CR• # <br /> 'i'C EXP. DATE <br /> 1 �5�� 1�" �_ 1/� C VALID TO DRIVEWAYS: <br /> (.Applicant: Name) STREET' ALU n <br /> AREA � QUAD + <br /> �>ae- PG I—/ v +C.2 o TYPE _ lk-=-Nn <br /> (Mailing Address) FORMS <br /> Jas S , C'4 l S-�'�' I NOTE <br /> (City, state, Up 'Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) � S� � ���t, Lh-td <br /> Post-it'm Fax Note 7671 ,Z ¢u Degos► �, <br /> To jv k From <br /> COJDept. Co. <br /> Phone# Phone# <br /> FurFax# <br /> The undersigned hereby applies for permission to excavate, cons ruct and/or <br /> otherwise encroach on Country Highway Right-of-Way on the w Bide Of <br /> sd M '5 . ap roximately a- (rU a /mile. <br /> of - 0�C) � , , by `pez arming hE <br /> fol}owing w rlc (deet iption. o wol*) : cL > b r <br /> r h� Ot- etc t� MAI/) 0 01 rk 0'Ciju*v{, <br /> L► <br /> to <br /> Work will, commence on, or about � for approximately <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, :regulations of San Joaquin, County and subject to <br /> inspections and approval . <br /> 0 :21 kid C 1 <br /> - <br /> 5 ature of Applicant Title Date <br />