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209-433-3990 p.9 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7c• — O/ - 00 <br /> GFFICE USE ONLY <br /> To. San Joaquin County Jag <br /> Department of'ublic Works REF <br /> APN <br /> EXR.DATE <br /> VALID <br /> (Applicant Name) STREET ------— TO [DRIVEWAYS. <br /> AREA QUAD <br /> TYPE , <br /> (Mailing Address) FORMS --.- — — <br /> C.4 `)S•3(0 'VOTES <br /> (City State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (jetailed plans may Ie submi edj <br /> I <br /> The undersigred hereby anplie:s for pe.-Mission to excavate,construct andior othepmse encroach on County Highwaa• ht-of--'Nay or, <br /> the weSY- _ <br /> - side c r�w ,.��,� approxi~"atefy /3 feeOf iI�c.ictc�-yt�.+•� �ii4�- U o� 6 by performing the following work(deson cf,Yrj : <br /> ..j� --5?•CL[. )/ / -fof <br /> r- 1 F4" ,PiLY r c .9-P <br /> -A :�isrteaf,Q fe l a-� Carltc�5M S. <br /> v1,'or c will cornrnence on or about <br /> for approximately ©r,.Q days. <br /> l:the unders;gried,cert that I am the owner of the respective proper_y,or am qualified to represent the owner and agree to do the <br /> rro'k described above it accordance with the rules and regulations of San Joaquin County and subject to iispection and approval. <br /> Signature of Applicant-Title <br /> Date <br /> F PIk:::Jvm•M.:,T(4Pti'i':I+Cf'"F•R:�FMJ AiK.A'"I;)hl//p,; ]•tin <br />