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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Se p i.rv►be r 21) Z01I OFFICE USE ONLY <br /> To: San Joaquin County JOB# Ilan REF# <br /> Department of Public Works pT APN CR# <br /> Will/A M J(D W r k — SAIL CS g5, .t,) EXP.DATE <br /> VALID 0 f//S/ DRIVEWAYS: <br /> (Applicant Name) STREET ' <br /> �DaD r roadalcv sit,'fe- (p75' AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS 5 <br /> GA 1 4(907 NOTES <br /> (City,State,Zip Code) <br /> o C,t : C551)&39-7055 GtIt:&4 o S <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> , GA�'6Q' 5'AIi g\�S� for � N !✓ rc c�,.� <br /> ►��R- <br /> The undersigned hereby appl' for permission to excavate,construct an orenNise encroach on County Highway Right-of-Way on <br /> the So(AA we side of r o h o af-4-wo 10c, imately 700& /,500 LWmlle ho r r wc5{- <br /> Of C. ranf- L,i A-e- o ,%074 e jon ,by performing the following work(aescn'ption of k): <br /> rave f4 re +t 0.s2. a; be -f o fhe- nor1- aveo�l er4-;cn o� �-1 e s oqt)der <br /> i- Al 0. eN 'Alli CRJ?-O� on f fnt.. VA -t Z• e,_ re-v i I be m <br /> oaf 104 lea <br /> rate fk� tela. 6n o -1-k-L low c5 in at�l-" Vn e e- oul er cLC; <br /> mo✓ vvt" 1x-60 �Lcr aG d ' A+7A ou a riC.tt, ta.ca. ro r <br /> v kiear e: /) ciscc,6o n , G awl LI AC , SEE C, ?�a i �j,� <br /> Work will commence on or about-?cfD foes lO, 7-011, for approAmately V S. ow <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 regulationso <br /> e.c:+ f San Joaquin County and subject to inspection and approval. <br /> Ak'40vi rola OC <br /> Skit- Fr Mama, eyl- <br /> Signature of Applicant-Title Date <br /> E:ft"V."C&%STMPSEIKRWCFCAEMPERWtAPPl1CIV710 WC(010) <br /> Gnhf . Gond rnr" P��n for $PCC,-F;C jova $�,ha.c�er dtl�iel� w;11 be, tAsed, <br /> 'Fi,L. Ch+'n-fy- -qfF fike 3 w«14 f roJee f-. S,jvieL e_ <br /> W i�t 10 -to-ken 'A"W►7 o 'fh e- Lw O.F Q QC�1 Ao l a VJ f� ` <br /> I le I;iA t e-3a.-1e✓ ro base. WX lx �wloV� �tP on �u-rti na��ol� <br /> 94-' +k-r f'r ,;j e: +# <br />