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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��/`��Z 4/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# j/ppp REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2 t d <br /> C, , rJ _ VALID // >v TO 2 6 DRIVEWAYS: <br /> (Applicant Name) STREET �� '/$,erjav <br /> ..r��? AREA �%#e L7 QUAD X f/ <br /> '5'J 2-0UGt/''G IJ S TYPE 7+ IGflG Lo trf-�G Z�t/�GES <br /> (Mailing Address) FORMS �- <br /> NOTES <br /> f�rtsn0 CAel3 7Z7 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of a3,C aet�rt't'E1�.)I�©1 �°, approximately #e4.1 S " <br /> of Ame ,by performing the following work(description of work): <br /> Work will commence on or about / '° for approximately 2f C days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title '/ Date / <br /> EVM-V.WMWTERPMOnACMW PEI3MITAPP"TM.DOC (011W <br />