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209-433-3990 <br /> p.3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I— OFFlCE USE ONLY <br /> To: San Joaquin County JOB f, //p al' REF# <br /> Department of Public Works APN CR# <br /> t32-tin H o-��ma•, �jc� — - _ <br /> ewes;5 Fy EXP.DATE <br /> :nP er;.G� c t2ac e.�clvp,ne,:f Lee VALID TO DRIVEWAYS ' <br /> (Applicant Name) STREET �/R,�rD�r�aQg9QS <br /> 3 S/ ut ssy?v�od AREA — QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOES <br /> (City,State,Zip Corte) <br /> (Area Code-Telephone Number) "-- <br /> Sketch;Detailed olans may be submitted) <br /> I <br /> The undersigned hereby applies for permission to excavate,construct andfor otherwise encroach on County Highway Ri ht-ofi Way on <br /> the side of_W, &r tori 1 s/ 1 , ✓ approximate!y 0rt.x <br /> v4 * feet) yes <br /> of i fi[rst c t7o� tet1 q tea/ �',. e,- +C'e( <br /> PF by performing the fcIImMng work(descnption of,mxk): <br /> _ U t a.'7�. S � r -fo a �+K n?S f-¢e� ¢/o... rQ...r�Svr�aa <br /> ^ LL SGr" Ge.1r o+irre�r✓et .¢.- S'e�rr„�1CQp � nna u�r// <br /> K. Pn r�ORO _ try '7"S iA7/htGf<0.'7'< 4'h'rt_G( Co/f[Ci 'S _.t!Sczm..c <br /> Work will commence cn or. about_ 11'0 1�t,20o Fj for approximately on.edays. <br /> ,,the undersigned,certify that i am the owner of the respective property,or am qualified to represent the cwmer and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subjee,to inspection and approva. <br /> Signature of Applicant-Title Date <br /> i J'l^n;iJv,Y.J._'kia�t`!Yp.;;Mt'EY(F]tWI.i RICi:glv.Px: ;J'1C8] <br />