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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> F <br /> FpFICE USE ONLY <br /> To : San Joaquin County � !"3 REF <br /> Department of Public Works CR ##'! i i i, J� 74�nT 1 I DRIVEWAYS: <br /> (Applicant Name) STREET 1:5 , <br /> AREA tEd cXrar4QUAD 15S <br /> CTS, r �fs.L. l TYPE _ <br /> E R 1• ,li_LC3_ <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 20f <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> f <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the r- r"57 <br /> S'4y <br /> r- approximately ,'0e side of <br /> ee <br /> of ss - f. t/mile <br /> following work (description of work) : , -T 4by Performing the L• <br /> �cc �Cerc1� 1(y itbsrx� 0— e Cv�C(c�:ihJ. <br /> d �rtx �ae�c%rn {'xrsf,n cry can liew C6;rrt arzd fe ce <br /> Fyn Con�v:fS - f 1�« r� �" rnr�er//ter/' �,ron ,00k' fu r,�ti, �y� .✓t� !!.t'G f�-L/'f;� <br /> _sL�'�rR' (lCr'F Ctr°� :,TJfegc yrtDn GJ Ill iaE [,C C'� L..'X11 �' rl �/•r�eti <br /> Weak will commence on or about <br /> 151_1days for approximately <br /> -, she undersigned certif,. that <br /> r am the ewrer cf the respective ro erty, <br /> 4ualified to represent P P r am <br /> the c ar:er and agree to do she wcrk described abo-:e <br /> accordance with the rules, regulations of San Joaquin County and subject <br /> ins?pect ion and appro,.al. - <br /> pp jr <br /> Signata of Applicant - Title ---- __ <br /> Date <br />