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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 11 <br /> Date 104; 1 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7;w - REF# " <br /> Department of Public Works APN SCR# <br /> EXP.DATE <br /> VALID 2 TO DRIVEWAYS: <br /> (Applicant Name) STREET Gels <br /> AREA ethanQUAD .d5LE <br /> pa'v .< (�m� TYPE T!L S <br /> (mailing huuraa1 FORMS S l�tl1 -L <br /> NOTES <br /> ,-Ay,state,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 4'� 'f�� it e✓wa' <br /> The undersi ned hereby anrlies for permission to excavate,construct and/or othe iso inrro hon unty Highway Right-of-Way on <br /> the 2 o /•>;53 S10o n ► at <br /> of uy,,,,rforrning the followi g work(description or work): <br /> int �'!.1✓ io' la►r �" <br /> R(9 FL m M Q ('���a,�r�� Err�s� � �o' FMt 750' T12�•><� <br /> 4 �/f RE7vt&VC- � kPie k 'LA-rves. "r oiFcH Ik i Al- 2np 2-tw <br /> 5`x t.l✓5 5'x to, MU�t-e5 �f -r yip" <br /> I oo' sEt'- GE <br /> Work will commence on or about 11A. I I for approximately 1!+ days. <br /> I, undersigned,certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> ork described above in,6cb9rdance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> i nature of A"ea <br /> li nt-Title Date <br /> E:WU&SV. 0.'.EN:"..ENT AF7ULATONDOC )01=) <br />