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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date !2- OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works AP73� '3 REF# <br /> N CR# _ <br /> EXP. DATE <br /> P AL1 1J--1 G t3 h.l.L 0 3 b S A TT VALID <br /> la 11 <br /> (Applicant Name) -311TO 2 it DRIVEWAYS: <br /> STREET ,Fieo S P.�AC�S " Y451) <br /> AREA A:-4ePvt:> QUAD <br /> L� U D C2 �S1 N ,t LCi (ZC] TYPE — <br /> i oaRr` ( �l(r -ldtES T�Eft�'r�1 <br /> (Mailing Address) FORMS <br /> NOTES <br /> ST 0C,lC , b 1J CA Q 21D <br /> (City, State,Zip Code) <br /> 1.20'k� L41 Ll— K O 3 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans maybe submitted) <br /> P L Ci nS�L S r7 <br /> I ! <br /> i I <br /> i <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the VV r,, S7 side of H k3 Y—q e, <br /> --_-- approximately—�O <br /> -- -- — --- --- feet'mile _ <br /> of �20tJTA�� ROI�D --- <br /> ----- -------- <br /> -SIDSS t#--LW--�9 b performing the following work (description of work): <br /> i!nG I N tom- 13btZ� J �. - - - y p 9 <br /> CC tV A 1zs 70 Iplm-t 2 Li GPC CLT�j U1 7-5 <br /> �c20_SS_4_i.t Y-5S /XPip rl i 0ACJ5 (-U1�Ii! -2 ► Pt iS 11J`t0 I <br /> _:L Rc r�N D ('�;')t� r'T ► 41�1� TO Cid t4 i i1UG Pi.hty 4.�Jd' `�� �� F W f\LY-- - - - <br /> -- ---- <br /> 1�1�r O %�S-1 0 C L F A CZ <br /> Work will commence on or about- -' � 0�F3V 9-T, _ <br /> for approximately gays. <br /> 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 /> ;,ork described above �n accordance . ith the rules and regulations of San Joaquin County and subject to inspection aro approval. <br /> Sig ture of Applicant- Tie <br /> Date <br />