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APPLICATION FOR ENCROACEMEN'f PERMIT <br /> PLEASE PRINT: <br /> Date to . ^, <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> FE Department of PublicWorksR.EF # <br /> CR• <br /> T <br /> � c ti VALIDg- <br /> (Applicant Name) 1 TO DRIVEWAYS: <br /> STREET y_41�t �.nrQ�.r,,.LS �. <br /> AREAS is QUAD ` -- <br /> TYPE <br /> (Mailing Adc'seas} FORMS <br /> NOTEZS� i15 <br /> ' <br /> (City, 'State, .zip Code) <br /> Vk <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> k a , <br /> g <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise encroach on County.Highway Right-of-Wa on• e th <br /> y.. ...�� .• . side..bf:.. . ... <br /> of approximately feet/mile <br /> following work (description_'work) : <br /> ! � by -P <br /> by the <br /> M <br /> Work will commence onor v � ' ' "`kt�e r <br /> °+cZ3 about ( i <br /> days. - for approximately <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, xegulations 'of San Joaqu.•in <br /> inspection and approval. County and subject to <br /> a k ffa <br /> Signature of Applicant <br /> Title <br /> Date <br /> NASTBR.PS\PSES®L (6/00) .. <br /> - I <br />