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APPLICATION FOR EN'CROACBM= PERMIT <br /> PLEASE PRINT <br /> Dane ; 1 00FICE U5Z ort Y <br /> To; San Joaquin County Q?3_#, � REE' # <br /> Department of Public Works APN Ciz: # <br /> EXP. DA'T'E �+� <br /> 0 DRIVEWAYS; <br /> (,applicant Name) STREET --- <br /> r� <br /> ARF-B. e� QUAD <br /> G 4i✓m i fgzs-': "C& F,aT" `TYPE " ------ <br /> (Nailing Address) FORMS -" — <br /> NOTE j <br /> (City, State, zip 'code) <br /> 5�` - ��4 -7 -S?if5' <br /> (.Area Corte •- Tolephone Number) <br /> Sketch (Detaned plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on. County Highway Right-of-•Way on the AMPIA d- 5"T'� side of <br /> Klpor� v eapproximately yZ 00 feat mile <br /> Sut GA5 rrr.ar�+ by performing the <br /> of Y" 1314-Anuc E ,4PAU, eKe6o' tw c:AS strRt.� <br /> following work: (description Of work) : P� <br /> ON rot SCury sq2g OF k'.tP9 ?Q Twe 'o N I jej <br /> Work will commence on or a:oout: Ocrogot\' for approximately <br /> 30 — days . <br /> Y, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do tae work described above in <br /> accordance wi-zh the rules, regul.atione of Sar. Joaquin County and qubject to <br /> inspection and approval . <br /> -- z <br /> Soy. 1-+ov5cPP/11u - GFiS EST&wATOL <br /> signature of Applicant - Title Date <br /> .'+IAS'T&A.rs\L•EEeC`aDL (f/001 <br /> Z,0/ZB 39Vd SlIW�Gd 03fS bZ6689b6aZ LB bI 80aZ,lLZ!ZB <br />