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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> _ <br /> Date OYFICE USE ONLY <br /> To, San Joaquin County 2013_# .13001591-- REF # <br /> Department of Public Works A.PN I I CR <br /> EXP. DATE &011t7lh <br /> b VALID '2- �0 ;)R:EVEWAyS. <br /> 1_* <br /> (Applicarit Name) STREET <br /> -Al <br /> AREA QUAD <br /> TYPE -101ye"An-0(fo <br /> (Mailing AddreaS) FORMS 4Q/Z,44N�' <br /> NOTE <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 <br /> otherwise encroach on County Highway Right-of-Way on the -f- 3,Lr2; 5ida of <br /> approximately feet/mile• <br /> of by performing the <br /> following work (description of work) : <br /> Work will commence on or about for approximately <br /> days . <br /> 1, the undersigned certify that I am the owner of the respective property, or am <br /> qv.alif ied to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San joaqruin, county and subject to <br /> inspection and approval, <br /> Signature of Applicant - Title Date <br /> ,4ASTER <br /> -Fs\7EZ8CuDL <br /> Z0/Z0 397d SiIH63d 03rS VZ6689060Z `(3 :t?T <br />