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Ff_B :. 3 211{' <br /> ppFR.ESi�0 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:'D,,"DFe'C <br /> Date <br /> _j3_1 f I� <br /> OFFICE USE ONLY <br /> To: San Joaquin County [JOB# 7jra_ REF# <br /> Department of Public Works APN <br /> CR# <br /> PCL ��C c� GA d-E IC'G--lr^� G EXP.DATE l2 <br /> (Applicant-Name) VALIDSTREET 0D� �� DRIVEWAYS: <br /> AREA <br /> g _ I— cxr, I(, P�. C Cc��� TYPE _ QUAD Ike <br /> (Mailing Address] FORMS cErrtE <br /> T_—re's 'o O NOTES <br /> (City,State,Zip Code) X <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �jE_�_• S ��-IZ � <br /> Acf-os � L4 q 309 0� r73 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way o <br /> the u.S side of J c��l�1b <br /> Of /���#,�" - _--� -approximately '2ZSo ile <br /> by performing the following work escription of work): <br /> C1 it <br /> f= <br /> -* o ,G7AP 414arel'a2E 9+ie,itF�rL <br /> Work will commence on or about a <br /> for approximately I 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 /> Signature of Applicant-Title <br /> Date <br /> E:IPU&SV.WKIWASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01/08) <br />