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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date *416 ' <br /> OFFICE USE ONLY <br /> To: San Joaquin county A Q ? <br /> Department of Public Works JOB # (���71-`� REF ## <br /> APN R" # <br /> --------- <br /> EXP. DA—T <br /> 0 <br /> (Applicant Name) VALID a TSTREET 10 DRIVEWAYS: <br /> -�o(9 l.� <br /> AREA <br /> A2T �_ QUAD E$ <br /> (Mailing Address) FORMS <br /> 1rrc'��i�./ rr "✓�"it' NOTE <br /> (City, State, zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, <br /> otherwise encroach on c'oun.ty Highway Right-of-Way construct and/or <br /> r44�k h` y on the C)v,h' <br /> of �i.11Tko��y. t,r approximately _ side of <br /> 14A r;' _ "fee /mile <br /> following work (descriptio:n of work) : , �'u« � <br /> T by performing the <br /> l Low 7f ' Lrct7I iso v , �c "v�E' Gk/Ccl1 <br /> Al— / -Jorc <br /> r"d/D coYPc� - Tf/C P'Ciop mf' .uc�t Fidsiy�DTv C'tS�v/zt Vii/ L•rF 5 u"7%f <br /> Wcrk will commence on or about <br /> <u -<�5 �Ga�o <br /> days. for approximately <br /> the undersigned certify that Z <br /> 1ua ed to r=-pre ,� am the ow:-�er of the respective p or <br /> lif i -�F:_t resp ti�e ro <br /> e o'�r.er and agree to do e erty am <br /> acccrdance with the rules, =re work described abc e in <br /> regulations of San Joaquin County and sub' <br /> inspection an4/XXporoval. <br /> i subject to <br /> Si ture of A <br /> pplicant - TitlefC <br /> Date <br />