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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ( t <br /> f OFFICE USE ONLY <br /> To: San Joaquin County I JOB# 110006- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATEZ et <br /> VALID t t8 T 2 titDRIVEWAYS: <br /> (Applicant Name) STREET <br /> 1 AREA QUA <br /> i2( ( St-reed TYPEcZtlsC�S -i <br /> (Mailing Address) FORMS <br /> NOTES --' <br /> (City, State,Zip Code) -----j <br /> c� -_ 2 - 3 <br /> (Area Code-Telephone Number) — ----{ <br /> Sketch(Detailed plans may be submitted) <br /> ! � I <br /> i <br /> fI I <br /> I <br /> I <br /> j <br /> ; <br /> i <br /> i I <br /> Ii I <br /> 1 � <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 'We% Ca t` side of S R 9 R 'aAft-IaA - Rd Sovt%%Ir-wl�,�approximately i 5 t3 feetlmile N o AT <br /> of -�Tt1AoQ Roy MauTEc,a ii <br /> by performing the following work(description of work): <br /> oto+�c.n,c�,: or ,nas �-d ca otX-'r»ry eta cep- Srt+ r0. 1a hce <br /> oVgreV_nt w��Ftf t�,:it iec town t� sr m c + -it\tS c ;ti lle <br /> !hOr+'+v <br /> Work will commence on or about for approximately r days. <br /> 1,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 /> ig ure of Applicant- tle' Date <br /> ;. <br /> E:tPUB <br /> fAV'Af .W1$iER.P51£NCROACHMEP7 .V <br /> PER ':APPLICA^CN.IXT;(0!gII) <br /> ' <br />