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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2yI C� Y OFFICE USE ONLY <br /> To: San Joaquin County JOB# �j�DO��— REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> V rG��l-z-0 VALID 227 . � O 3 /S 7• DRIVEWAYS: <br /> (Applicant Name) STREET w/� ,Q/I i��• <br /> /� AREA IPGvV QUAD _ <br /> 4- 0vi t_E f�T-C. TYPE P— <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> ZOff /23ct 02 C&� <br /> (Area Code-Telephone Number) <br /> Sketch(Detaile 150 _-VtAoi-K CIMMIJi t ICS' Dc 111 <br /> 9)C<9-PA f-lx%t M W FA-�L 9?Llri 50K ?RVEj�,u3T\ <br /> 22' o a � oq Chow �a' <br /> C,1L <br /> f�f.PL. Fcra-ll <br /> 055 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EA-5T side of N I PO N CZ D , �x-��r DWG approximately I V D0 feet/oe MO N t-1 <br /> of m EL L_O /kJ Rt9D hJ by performing the following work(description of work): <br /> IN Cl� 'L'L 5' OFF <br /> AT O(F-PTN D 3'a" . VE�tzo,,J CU�EMTL-f <br /> ITEC � i f T 4`�AS t Ota P�P�� 0�9 5(pLtC_� UDS \A) I LL B�-- <br /> a0(�-F— UND'C"K C_((aMkL KT 10, vt'vvkk <br /> AN►D UI\JOED �,pcP�kt. 30R� PITS PrQ�f 3'75'. <br /> Work will commence on or about Eci b. t'_RJ Lf 1"7 ,"Z01 Z for approximately \0 days. <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 /> 2012- <br /> Mla.-,41MA 0034 <br /> Signature of plicant-Title -- Date <br /> EW6SV.WIMUSTER-P-�BCROACHW-NTPE Wr APPLIGTIONWC P149 <br />