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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J-01 O e — ---- -- - <br /> -- - _ �- OFFICE USE ONLY i <br /> To: San Joaquin County r� <br /> Department of Public Works REF <br /> APN _ CR# <br /> A-( � ' EXP.DATE (•tS ------------ <br /> _ T (ATT+,�. S d1NhJE VALID i0•?�-OZOR TO t• 15--Ce - DRIVEWAYS: <br /> (Applicant Name) STREET . <br /> AREA E�� QUAD _ ----"---I <br /> _ ______ TYPE <br /> (Mailing Address) _ ' FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number)- _ ------ <br /> Sketch(Detailed—plans ans may be submitted) ----- L - ---- --- <br /> S� � � -T 7AGH4��J -- � <br /> i <br /> 1 J <br /> I <br /> I � <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 5 T <br /> --� side of-_LZ,V�. FL.p <br /> of G [?� a� -----------______.approximately feet/mile WEST <br /> T�Fid1 U A- 2 f - -- - --- by performing the following work(description of work): <br /> -- 4' __ �Ar E t: TAU K3 i IE'0 <br /> � � L-2 R¢ ANG 1► �!J �i;Vl! j�OLt- fit_ v�OT�- tS <br /> Pf�b�%n qr- Ut✓ 5 .3' LOGA� <br /> --mak Pn t- � � MC13r�� nG ry. R tZt DCrE 11r _ (T Te <br /> ork will commence on or about <br /> days.--- -- <br /> I, the undersigned, certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspect-on and approval <br /> 1 <br /> r <br /> Signature t Applicant Tit 400tle - - - / <br /> Date <br /> Fu.`g C-L%I^t S!A.'ArF LICA 7 Ar!f LI'4 <br />