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F"S 0o t '7e <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date rC%jC� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# "7_ jXn_& REF# <br /> Department of Public Works APN _ <br /> CR#> 0ATE <br /> �T%/ VALID <br /> TO i DRIVEWAYS: <br /> (Applicant Name) STREET ,qA1_4 <br /> .2OC? �lCzZplG�= AREA ®Df QUAD <br /> TYPE ��� <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State, Zip Code) <br /> �C�1 <br /> Y7471 %�2. S �. <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> -T—JC4 L i4(E-t <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the We� side of 11•)c t-.A t� <br /> of l'tA,i2N �,� approximately �O (mile uJ—tA <br /> '—� -� <br /> '5:'X , by performing the following work(description of work): <br /> ;� ;s4 TE lt. ? i ��y �t�- piEAsk_ke,'ti <br /> 5,P ►C Z r�t�iJ c t�C «Lt2vJ <br /> Work will commence on or about <br /> for approximately_ i c-- t S 2cktc 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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signat� of App cat�t 17 ZS 1(-) <br /> -Tit -- ` - <br /> Date <br /> E1PU8-SV.WKIMASTER.P NCROACHMENTPERMITAPPLICATi0NA0C <br />