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APPLICATION FOR ENCROAC14MENT PERMIT <br /> PLEASE PRINT: <br /> Date z ,'Ila /_'TA . C� 6' J�r OFFICE USE ONLY <br /> To: San Joaquin County JOB# —�j� r REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO / /0 DRIVEWAYS: <br /> (Applicant Name) STREET LA _ <br /> t — AREA "C l.�tq QUAD ___ <br /> F 3 1A: " c it <br /> C ,e' ► €It r���� �7�t',� TYPE 2+iCt� <br /> r <br /> (Mailing Address) FORMS <br /> 5 NOTES <br /> (City,State,Zip Code) <br /> � ✓€ rl <br /> (Area Code-Telephone Number) <br /> 1 Sketch(Detailed plans may be submitted) <br /> T. <br /> 4 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the €n side of . %r� e `� approximately "� feet/mile <br /> of f z �,� j., ��-r by performing the followingd <br /> t�E 1 r••�`x��'�r���"',��.. � ' � , , work( esFription of work): <br /> �i <br /> / t a!r <br /> Z:�( <br /> J i <br /> Work will commence on or about MA „ <br /> --- — � �° ✓' for approximately jQ days. <br /> I,the undersigned,certify that I am the owner of the respecfive property,or am qualified to represent the owner and agree to do the <br /> wodescribed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> �. � <br /> � tt° <br /> Signature of Applicant-Title Date <br /> EVPUBSV.WKL'AAS'ERPS%ENCRCACHMEpfr?ERMrrAP?;ICATION.WC (01/08) - <br />