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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date FAREA <br /> FFICE USE ONLY <br /> To: San Joaquin County 4 REF # <br /> Department of Public Works CR' ## <br /> /�=O�J TO _!S-DF3 DRIVEWAYS: <br /> (Applicarit Name) y QU�A+D C <br /> TYPE ,,,v <br /> (Mailing Address) FORMS�T� <br /> e__ /7 � NOTE <br /> (City, State, Z///ip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 61^10�d:4 WfQ/7Ck <br /> The undersigned hereby applies for permission to excavate; consruct and/or <br /> of riise en eoach on County Highway Right-of-Way on the <br /> ide <br /> e sof <br /> approximately �U fee /mile ,A�d <br /> of t // S7�ce�s�! <br /> fo lows, g wor� (depeript.ion of work) : X by performing the <br /> °�- _Z' GDT ✓«- be- a- u <br /> e� Tel ° a.b a oL c-k, - y C �S e Ub'r r a o <br /> 5' ;" rcu w e 0 - a e b r` I. <br /> Work w 1� commence on or about `' <br /> days. for approximatel <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 ruler, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applic t - Title <br /> Date <br /> M;S:'ER.FS\FEES=L (6/00) <br />