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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 67 ctl—,r,;20 <br /> �------ OFFICE USE ONLY <br /> To: San Joaquin County JOB #Department of Public Works REF ## <br /> APN CR # <br /> EXP. DATE `� <br /> (Applicant Name) VALID STREET 1V1---- DRIVEWAYS: <br /> �j <br /> AREA a--- QUAD 4.c... <br /> TYPE �4 tJG RaSsT G A A $o -----�— <br /> {Mailing Address) FORMS Ss ,r ---- <br /> if G� c,� NOTE <br /> (City, State, Zip Code) / <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> of erwise encr ach on County highway Right-of-Way n the <br /> h side f <br /> Of approximately eet ile <br /> follev owing work ;description of work Y performing t e <br /> o � <br /> Work 'wi 1 commence on or about (-e <br /> --ss'Q days. for approximately <br /> I, the undersigned certify that I am the owner of the respectivero erty, or am <br /> qualified to represent the owner and agree to do the work <br /> P P <br /> acccrdance with the rules, regulations of San Joaquin County sandbed subjab <br /> ecteton <br /> inspection and approval. <br /> r ` <br /> Signature of Appy— icant Title <br /> EEss <br /> iU, ��� Date <br /> �-F� 1✓✓L�'ff <br />