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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date CA - '3�(A - �O FDATE <br /> FICE USE ONLY <br /> To: San Joaquin County ,3 REF # <br /> Department of Public Works CR. # <br /> } TO / / / DRIVEWAYS: <br /> (Applicant Name) <br /> AREA QUAD 'Skil <br /> TYPE G CLES QES <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ci..t. .Y,-a <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the _AoZ q side of <br /> Gi� �Z l•.lE Rn approximately Sgo' feet <br /> ��► y�%is<'�i :'}til D <br /> T r C ,EL 12„4, Cl 4o c Lid T?2a v <br /> by performing the <br /> following work (description of work) : &Q.E 1- PLACE --1_y„ Cp (N� 5dou�� ct c,rt <br /> _L? o t G LL'-4 T ► !t [ �J iU�'?,J �i G- /E Q N EL f 4N Clio �fl P A 2x"'< /arca U <br /> 1 3XS� S+ isc <br /> 602E lu a - 01, SNS r2bvC� +e2 i6eV- 9LA(- ..(YIt-:-►aT' �� ' > Ori D�A.J C �2t <br /> Q.S 2_ , - <br /> 3ax <br /> tom' <br /> Work will commence on or about 11 /15 X10 <br /> N'S 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 /> -4 'J <br /> ?(-1 <br /> Signature of Applicant - Title Date <br /> YAS�ER.PS FEES� <br />