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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 �Z , �� OFFICE USE ONLY <br /> To: San Joaquin County JOB# IVA005- REF# <br /> Department of Public Works APN CR# <br /> 1 } t^ h EXP.DATE S /2 <br /> VALID � 0 5 20 �2 DRIVEWAYS: <br /> (Applicant Na e) STREET ouS ;eoADS <br /> AREA , .,SQUAD kJ <br /> 5 U 0 u5� t�,' ? } TYPEia�l�'�°19k�/ <br /> (Mailing Address) FORMS <br /> NOTES <br /> d <br /> `y (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> lC �� <C-e— <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of Cu,,\1-, iou45 approximately feet/mile <br /> of , by performing the following work(description of work): <br /> U >A IJ-1-1L1nt_ G4 fm iA- u Ywc,C� 6 fJ t� 9j" <br /> g t�.n t 1P w 12 J �n,11J 1 G` l IVAe . 1n it F,,Ar n�nl u l jln� <br /> l( Ufa caw _ wVk W—SJ <br /> Work will commence on or about 712---e) J U u,'.- W.w SIN,, for approximately L! 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 /> S• ature of pplicant-Title Date <br /> E:1PUB-SV WKIMASTER.PSIENCROACHMENT PERMIT APPUCATION.DOC (01108) <br />