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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t6A , i ns 2010OFFICE USE ONLY <br /> To: San Joaquin County JOB # 16��`�' REF # <br /> Department of Public Works APN CR # <br /> ATT EXP. DATE 7 1 <br /> TL�1¢s'icrl,f USa�t VALID I ` TO r )6 _ DRIVEWAYS: <br /> (Applicant Name) STREET to '54. , <br /> AREA CG 4�J QUAD �S <br /> TYPE a e gja�, f Qi1 <br /> (Mailing Address) FORMS - 9 <br /> 17 - NOTE <br /> (City, State, Zip Code) <br /> zC'r Cl i"`-1 'I <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 7,10 D r <br /> fi3art_ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the ,2kjoery c �007/Y side of <br /> —M AIA' �77 approximately `e eet/mile t 1 r <br /> r- <br /> of 0r'C 5; t - <br /> by performing the <br /> following work (description of work <br /> q <br /> LI(i 4,�>E i GAJ 52 4V f EJ 1l <br /> Co.VG i.','7 J I�L,AJ''f/ ��0!'0 i l i�w.�'s L K CD,t! .r`,rc7v✓ fr �/tJ . � � <br /> I fXl3cc� ?"/<' f lC I Lry L <br /> 4V kt J o S'L t9F���L S To L tkr Ok, <br /> Work will commence on or about p Zoic <br /> �, for approximately <br /> ars . <br /> u dens i neQe __>; fy that I am the owner of th e respectit;e prap.erty, --r am <br /> ai L - d to r_� es t the cwner and agree to do the worms .iesc <br /> ribed abc-re it: <br /> a dance with the rules, regulations 9� of San Jlaquin Cour-7:y and subject - <br /> 1 IsFection and appro-.al.. <br /> Si nature- of <br /> 5 cSApplicant - Title <br /> Date <br />