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APPLICATION FOR ENCROACHMENT PERMIT; <br /> PLEASE PRINT- <br /> Date (0 - \O - --- <br /> OFFICE USE ONLY <br /> To: San Joaquin County r1 <br /> Department of Public Works JOB # j 3� �r REF #_ APN T CR' <br /> _ <br /> EXP. DAT + <br /> -11.5'10 <br /> (A VALID o TO <br /> (Applicant Name) STREET �1l3'��C� � DRIVEWAYS: <br /> a 300 t< <br /> 1 G t 1"► �1 f t= AREA QUAD ------ <br /> (Mailing Address) <br /> FORMS - <br /> ��Ck-�t.� e NOTE <br /> (City, State, Zip Code) <br /> 40cl _ - 4Cde <br /> -����}(Area - Telephone Number) <br /> Fketchtailed plans may be submitted) <br /> trZS /�VT 'AC't-1�_0 SKSTCji <br /> L a�E �aT <br /> The undersigned hereby applies for <br /> County Permission to excavate <br /> s . fnA y Highway Right-of-Way on the me construct <br /> ct and/or <br /> otherwise encroach on n <br /> of VY%A� LA, � — -_ approximately a1 I q ' side of <br /> following work (description of work feet/mile rmLi <br /> ) SCZ E t�1C�� by Performing the <br /> 1Klo c Hy ,ha�ltr RD ltE au� �,, P� C� 1 - " t< A10vi r FYLC ,Yl <br /> x 5 T H lU t,1 ►s <br /> �Z1C iS �Z ��cc ►5o � Zo' sjo r"r ub= L Ti,�c 'ilk Ice E3C"c -,-,T <br /> - <br /> Is � �; .J p_ c-c T rik0 . oma[ S rwlra <br /> a� t oc_;4p t F�dc2 ►�71� iD <br /> A scQ �C D v t�L-t ti► <br /> Work will commence on or about ZD A�� " ° ►S �� <br /> --- days, for approximately <br /> Ithe undersigned certify that I am the owner of the respective <br /> qualified to represent the owner and agree to do r_ <br /> accordance with the rules Property, or am <br /> regulations of San Joaquin he work described above in <br /> inspection and approval. qu-n Count <br /> y and subject to <br /> Signature of Applicant <br /> - Title --------------- <br /> MAS:HR.FS`.,r^SHS,:�L (6!JO1 <br /> Date -- <br /> 9 <br /> f <br /> 3 <br />