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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County [APN <br /> B# _ ( I vvv REF# <br /> Department of Public Works CR# <br /> fEXP. DATE <br /> �SS L� Gi <br /> le-s VALID TO 2_[_2 dl Z DRIVEWAYS: <br /> (Applicant Name) STREET [• Ate, C� 6tA* b V <br /> AREA S`[�y-4d'K QUAD C T <br /> CUl�Gt l�i 0 �� I'd e- TYPE <br /> j (Mailing Address) FORMS &S/A <br /> Par CG j �Sj NOTES <br /> (City,State,2ip Code) <br /> (D3) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may/be submitted) <br /> -y6 G'f < dZClt 'GJ �rG �1'►�rll/ ��iVI <br /> wG& <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> _ <br /> HighfRight-of-Way onthe r a sideof Oa "Od A�r,� d oHn�i (/4$ �proximatelY <br /> ofSO <br /> ilewesf-- <br /> by performing the following work(description of work): <br /> _• Ctc�c C iA/e%/C -or Moi,hr' M <br /> Work will commence on or about / ,20 for approximately da s. <br /> Y <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 /> Signature of Applicant-Title ate <br /> E:IPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />