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APPLICATION FOR ENCROACHMENT PERT <br /> PLEASE PRINT: <br /> Date / �-- J t'R-0 6 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE tz14a$ _ <br /> Ll N ��ETLs�S 044 vaen`r-�- tvnc a VALID R 0 i DRIVEWAYS: <br /> (A plicant Name) STREET } , - -. <br /> '(�G> L-.l,voC'y�— �T ktS �,+a£ ZLs�-rc,c7- AREA i-1ax*0 QUAD I�E� <br /> TYPE 7wmo" 4", <br /> (Mailing Address) FORMS i <br /> NOTES 9'b <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> X cruet ms's <br /> �JJ <br /> J <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the _ �f ,SW"f ZAA C3 e c Pts WT S T approximately feettmile <br /> of I , by performing the following work(description of work): <br /> &&71V EEE'^J 20JV l*A-w, S7- 4- l ?ILL St s!1 A., G�Z ---V7 +r,i 2-OOV <br /> Work will commence on or about 3©O for approximately U 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 inspection and approval. <br /> til t C o C-ra,t-r Pi c`5. t <br /> ignature of Applicant-Title tate <br /> Y:''FOAM<L TEMPLATESENCROACHMENT PERMIT APPUCATION.doc JOW06) <br />