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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRWT: <br /> Date A��,(av t ! OFFICE USE ONLY <br /> To: San Joaquin County JOB# j 1 oon s- REF# <br /> Department of Pubk Works APN CR# <br /> EXP.DATE 2 W t I <br /> W.4dkit Cc.i'_.e� t.�1.,,p �,�,t Lae e VAUD -Z .4 it TO Zt tt DRIVEWAYS: <br /> (Applicant Narne) STREET <br /> AREA STdcKilll�E QUAD �Ir— i <br /> Sot S TYPE 's R r�vQ�,c �v►7r�te,L <br /> Milling Address) FORMS <br /> NOTES � <br /> Fite:►.o� C4 193' 17 <br /> (City,State,Zip Code) <br /> 544 - 940- ��►�_ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plan&may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise W aoach on County Hglvir4 Rigtlt-of--Way on <br /> the side of appro)dmately feefti e <br /> Of ,by performing the following work(description of work): <br /> 1111�A tIA�-th C� A 1114/ 1(�l`�AflL llihre.Z'.iw< 4'�` <br /> 1 <br /> S <br /> Work will commence on or about1 <br /> 7f an r l 1/x t;.a it_for approArnately j 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 approve. <br /> S' re of Applicant-Title tate <br /> E+nsay.WAWA"L"8CRoio.errKMMrAPK=Yo 000 i;noq <br />