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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ) t� <br /> Date J/ I 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73Lx REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE J911V12, <br /> -Coe 6A 6 �c,( �)-cG f y i L C��,,e,p� VALID � TO 5� DRIVEWAYS: <br /> (Applicant Name) STREET E2 .4 <br /> tt.,, AREA lOfll QUAD NJJ <br /> ,37-5 /V 1�/)��' � � TYPE -06I.(, D- <br /> Mailing Address) FORMS T A) SI I <br /> NOTES <br /> CA <br /> (City,State,Zip Code) <br /> N- g3:3a <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> JI�'-J��7av�4�l�/�Gs�/?� S�a�/•�!'G��+�Gr id���i ��®S/S.�j�/GqQ���'rai✓r' CL��� <br /> IVO <br /> df- /Y�!/SC1��fZT' !d /Y✓%�lii1✓/�n9 �!� !�'IG� �!?iG<G" X!��(�/ �ia�e. <br /> / Wa1'k/�/sUee n /9:00,4 V, �'Q �•��� .�:tet. ���r���cr ��a <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> theSp-jk Sp-jside of —71rnx { cam approximately 19-4o I feg mile c7ek5f <br /> of v P s 2 by performing the following work(description of work): <br /> RIC J2 <br /> 0^ OLI i7i'rj c �J� �✓ dl �T� i,� 11 h /c <br /> �•,.lyeS J- '?D' ;2f,aL its'aCi`•ciya is •int /l/L.� <br /> -T f <br /> Work will commence on or about '�3GiLf ;aUt2 for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and ree 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 �/Date <br /> E.PC�UMV.WWWSTER.PSENCROAGNMENT PERMIT APPLICATION.DOC (01108) <br />