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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date – <br /> -----_ OFFICE USE ONLY <br /> To: San Joaquin County JDB# ffpQ53 REF# i <br /> Department of Public Works APN CR# <br /> � Lr �3►�z r2 r EXP.DATE / ®/L <br /> VALID eo /3 a TO DRIVEWAYS: <br /> (Applicant'Name STREET <br /> LA--4 �, cY B4i/Il� <br /> E STC� AREA Tl�y QUAD 5560 <br /> TYPE , y -z1I/L�G'.w�rt7i` <br /> (Mailing Address) FORMS 5s � <br /> /civ <br /> C7 NOTES�S�- � Ca5tarQE „� L�G� ou <br /> -�—(C State,zip Cone) one L` 2S OPEI�e� -tr-p N2t�uG 1� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans=maybe submitted) <br /> gem <br /> FNI <br /> LI J TP/CA/ it Rc'>su-44�„ r <br /> The undersigned hereby applies for permission to excavate;construct andlor otherwise encroach on County Highway Right-of-Way on <br /> he ERs7-4.cvf-st side of iRnc �3 z,./ <br /> .S c,Mtr I racy 8P tx.� 4t- approximately a 000, feeYn4Ie o-3 8 r1,to <br /> Rak&.y rrfFe:ta,dlalby performing the following work(description of work): <br /> ' 6A) fl h <br /> v• nfLt^ t -Fri el _Z d a 2v <br /> 0`1 .d 2 4d C'{, Q}t n �Rc1�� Lauei'Y <br /> G n•».e"�-r � „� !-}�� •�� 4�� wr-f.L 3�p c.�tla.lJz� u� <br /> pee <br /> � <br /> — -- <br /> Work wilt commence on orabou#_ = / J <br /> !a /3 6�1 for approximately <br /> <ays. <br /> I:the undersigned,certify that i am the owner of 4he 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 /> � `G G�T�if-r!✓,i'_ Tk�G�l.�s c� t���',� l r7 <br /> Sig t �ofAp licant-Title <br /> Date <br /> Ei°UBSVAYk44{$TERy37FhCgpAapi[NI PEIGIIf AA'IICATIGV.000(OiMJ <br />