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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> To: San Joaquin County 1i JOB# I Lno REF# <br /> D(=partment of Public Works I APN CR# <br /> ! EXP.DATE "-}5y - 2_(�> i i <br /> -1c,[,'TO DRIVEWAYS: <br /> oo 1P <br /> VALID <br /> (Applicant Name) STREET <br /> D <br /> 1_Q <br /> AREA <br /> K TYPE <br /> (Mailing Address) 1 FORMS <br /> NOTES <br /> f 5 0 <br /> (City,State,Zip Code) <br /> L <br /> .Area Code-Telephone Number) <br /> Sketch(Derailed plans maybe submitted) <br /> -./oockrof."Ae- 141-. <br /> 4e <br /> The undersigned hereby applies for permission to excavate,construct andflor otherwise encroach on County.Highway Right-of-Way on <br /> the 1e>o-- sideSof `n/9,2J )io ipsi.e— 19,y. —approximately feetmile W-05� <br /> OF <br /> by performing the following work(description of work): <br /> Work will commence on or about—0,S- s approximately -------days. <br /> - <br /> I.the undersi-giried,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 /> Signet A plic Title Date <br />