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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �C TodaR L 1�1 2-0j D OFFICE USE ONLY <br /> To: San Joaquin County JOB# ��'A/ REF# <br /> Department of Public Works APN CR# <br /> T11 OF F� &OW! EXP.DATE` AF C VALID -Z-/O- T DRIVEWAYS: <br /> (Applicant Name) STREET ' <br /> _ AREA <br /> TYPE <br /> QUAD <br /> (Mailing Address) FORMS <br /> r , R 3�� NOTES A40 <br /> (City, State,Zip Code) <br /> (201) q6&- <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> L_. <br /> The undersined hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of.. Ln ul S E La-�i V C approximately of --� pp y feet/mile <br /> 27 <br /> ✓ >by performing the following work(description of work): <br /> S15 OF — L <br /> L rA <br /> Work will commence on or about farapproximately <br /> 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 /> Sc 10 <br /> �tto ✓ �l�tr /0 • "q4taS71gnature of Applicant-Title dDc7 ULLOADate <br /> �E <br /> E:1PU&SV.WKNIASTERPSIENCROACHMENT PERMIT APPLICATIONAOC (CIA" <br />