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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date , f OFFICE USE ONLY <br /> To: San Joaquin County JOB# TO REF# <br /> Department of Public Works APNCR# <br /> EXP.DATE &WA'-'ft'J <br /> 12©` ` f ���' �S VALID 7 Q DRIVEWAYS: <br /> (Applicant Name) STREETx <br /> 3 �� s AREA STia,t'ly,� QUAD — 5 <br /> C r j-r ` TYPE c emirs Srb i 5rsr1 <br /> (Mailing Address) FORMS <br /> NOTES <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,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> Of by performing the following work(descripfion of work): <br /> Work will commence on or about for approximately 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 /> worbed yin acc ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E1PUS'WWVMSMERPMNCRMCHMEWPEkCTAPPUCATIM.000(011M <br />