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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY --� <br /> To: San Joaqu n County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> I Arc I `" - LGYlL°P VALID <br /> 0—�— ;3€,° TO —2 DRIVEWAYS: <br /> (Applicant Name) STREETr <br /> �15-D — ,i., i a I AREA !�'�r� ps' QUAD <br /> Inra -er a TYPE <br /> (Mailing Address) FORMS S5l fNvv: �2G <br /> NOTES <br /> We �- ,� 9s <br /> Q 5 S C ter' AJ , � <br /> (City,State, Zip Code) --� <br /> I <br /> (Area Code-Telephone Number) -----~ <br /> Sketch(Detailed plans may be submitted) <br /> C, S <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Fight-of-Way on <br /> the &oe'rw sideof -V��,u _ approximately_ f,et/rrile rlkST <br /> of I�pA r by performing the following work(descr:ntion of work): <br /> Y !s /� o OoSE.A �'o N 5 s 6t L L 5 o r ®° ti c{ '` ., 6z ,qw <br /> _ -c ar`rrt' ' Sr D11- ter= •4y A10 i, D Lftevyr R25 .`. <br /> KAA h 7b �J t» � ati A- F' <br /> Work will commence on or about S4&47' for approximately. Z 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 i i accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> o_ <br /> uAS <br /> Signature of Applicant•,Iitle Date <br /> 'U'UBSVIWNIM,ISTFR.PSIENCROACHMF.NTPCIZMITAPPLICATIONDOC pug) <br /> �.�{��, ✓ x. ^-1 tf \,fie. w <br /> t <br />