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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �_ g ? OFFICE USE ONLY <br /> To: San Joaquin County JOB# Q REF# <br /> Department of Public Works APN CR# <br /> f EXP.DATE �:I "-•60 <br /> �w�t. r aril ' > �C� ^l r'�st VALID •Z((.- 10 TO DRIVEWAYS: <br /> (Applicant Name) STREET pus <br /> AREA 74rkM QUAD ' <br /> wrTYPE <br /> (Mailing Address) FORMS <br /> /Sir )r J/�/✓'{ NOTES L YZ! C" ✓ {rJ I -)- e) <br /> (City, State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be suVd) F L <br /> 30 e <br /> 4 <br /> tjJr- <br /> v-e r <br /> y <br /> de r,l S C r II G mi <br /> The undersigned here- r rt 5 <br /> y applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ side of— approximately feet/mile <br /> of by performing the following work(description of work): <br /> tiY-� _7 rti_^ � � z ci W�rl 1 iw/n t'trf raSSF s5 hr3c�ic',t6^un� uV i"arA��f✓.�, T c t` <br /> flair✓/L c! I,?i,r '�{L of L��,:if i:',atr o� Inf'... l arm .+ct l� �r..ctl� t L'lL sPt✓c1 � ( �! // <br /> t,� �.t i.^e:Y�t.''"1 � "9 aI i �1 - C. F Jti r j .�n..l'. ^.n rtFjce^".. �'.�.n J,';f ( i^'1 t•s/1 <br /> C• / Se t _ <br /> Work will comme e on or about for apprdximately jO w rGr r 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 /> Signature of Applicant-Title Date <br /> EIPUB SVWKIMASTERPSIENCROACHMENTPERMTAPPLICAT;CM1 DOC (01)08) <br />