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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �-- Q - Z b/ l OFFICE USE ONLY i <br /> I <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN <br /> CR# <br /> � EXP.DATE /�!f <br /> VALID TO N _ DRIVEWAYS: <br /> (Applicant Name) STREETX�h ,moo <br /> r AREA 571ct72a/QUAD AIIAI <br /> x,304) C /&/17- /IQ TYPE T AzH.,rJ utTS <br /> (Mailing Address) FORMS SS �,✓ <br /> a9c&201 1Q sa In <br /> NOTES <br /> (City,State,Zip Code) <br /> /3G4/ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �Ilg4se S 2 e- 1477"k'lwe0 <br /> 4�r_7_ PZZQe67_ ;e (gL6n 3`� <br /> The undersigned hereby applies for permission to excavate,construct an r otherwise encroach on CountyHighway Right-of-Way on <br /> theZA-fr 4 WArside of L t��t S�C�.A/hIIG/Tti XcXpproximateiy 3Cb l" feet/mile_ <br /> of lr� t� !S- �i/ !1J Y ,by performing the following work(description of work): <br /> L C3 3Yfrz. <br /> TunwrA torw/ fvorafr 4&o <br /> Work will commence on or about for approximately _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 /> O�-"Zoe -- <br /> Signature of plicant-Title Date <br /> E P53 dV 111:`ACA.`Pi_RP^EN(RGA:MdEN`PERW,A7R'GA-04 OU' <br />