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APPLICATIOIN FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County � - <br /> Department of Public Works JOB # s` (' REF # <br /> APN CR' <br /> to i t i.-. EXP. DATE #— ( {� <br /> (Applicant Name) VALID TOi -- DRIVEWAYS: <br /> STREET _ vim 4 <br /> 4.G't e Vit u_ AREA 43Rt�P <br /> QUAD <br /> (Mailing Address) TYPE �e"i-ioi F_,e ---- <br /> FORMSr Z S W -------— <br /> �Z�l ►� CfA 1i S 4 to NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A 04 C1 C <br /> The undersigned hereby applies for permission to excavate <br /> County Hi hwa construct and/or <br /> otherwise encroach on Co <br /> �,��{ � �,� �� g y Right-of-Way on the S0\2, p-�- <br /> approximately side of <br /> -e€ S j`\/_\,1TV4 Ear RD f-ee 1 e 14 <br /> following work (description of work) : ' <br /> Lc (i__y�c ��r by performing the <br /> 0"A " wIDJ 1'T" • rr.l ;l4 t {�S y j i t� p ---_—' <br /> a0 s2'�' � ',t"-- � SCE l L <br /> i , k e G T*1T�v2 s Ti A T"E <br /> RaLY} cp —i tit - �— i3o <br /> t£ O ti t�sc <br /> Work will commence on or about its <br /> *5 - days. for approximately <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 th <br /> accordance with qu h the rules, regulations of San Joa enwCouork described above ir: <br /> inspection and approval. County and subject to <br /> Signature of Applicant - Title ` `�- 6 C• <br /> Date <br /> .AS:'ER.FS`.?c ES��:, (5'".. <br />