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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dateyk-U QRFICE USE ONLY <br /> To: San Joaquin County REF <br /> Department of Public Works APN CR # <br /> EXP. DATE 6 r <br /> VALID. 9&,Z& L 6 DRIVEWAYS: <br /> {Applicant Name) STREET <br /> AREA Qu.AD <br /> TYPE -p�°�'' ,�v'A- <br /> (Mailing Address) FORMS <br /> ®A-1N.o �� NOTE <br /> 1( (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> l <br /> �u•- r :° <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach-on county.Highway Right-of-Way•oa the <br /> approximately feet/mile - <br /> of bey=performing the <br /> following work (description of:work) : # -e <br /> 01 <br /> :L IC.tl,f <br /> Work will commence on or'about ' for approximately <br /> _ days, . <br /> I, the undersigned certify that I am the owner' of. the respective -property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations 'of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant - Title Date <br /> MASTER.YSVERSCEIDL (6/00) - . <br />