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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OCTMER I_20 0 <br /> OFFICE USE ONLY <br /> To: San Joaquin n Count; JOB #_ � D'�?�. REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DATE 2 <br /> CNL.0 F Q$?SM\I �, 5 ��i vALID i� o .z a DRIVEtaAYs <br /> {Applicant Name) STREET 11J1,{S <br /> AREA. cam� 0= All TYPE <br /> (Mailing Address} FORMS 7 <br /> NOTE . <br /> (City, State, .:Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> _SEL lid✓-1 F A 7A 1,,LU <br /> WU <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach•on County•Highway Right-of-Way--aa-the <br /> of - <br /> approximately feet/mile <br /> ' <br /> following work (descripti.on of:work) : t 'RAIS _037F VAJl1F Q XEN7�:1 FNALG 2AQ� EPL F <br /> cAs-)nrrs .SNL car Asarrr.� <br /> Alli ZJ Klel[I;Ur. ON Pili AVE. ,ANLL W_fC1JJL�AYE - <br /> 6 C�9T� YIaLV� T Qifi �'x�.'13FZL •fit%61� - . <br /> Work will commence on or'about <br /> days. - <br /> for approximately <br /> I, the undersigned certify that I am the owner of. the respective •property' or am <br /> qualified to represent the owner and agree to do the Mork described above in <br /> accordance with the rules, regulations 'of San Joaquin County and subject to <br /> inspection and approval. <br /> LOREMAN <br /> Si tune of Applicant Title <br /> Date <br /> 24ASTRR_PS\P$FS®L (6/00) - . <br />