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r <br /> PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> 1 \Department of Public Works JOB# <br /> �R S� ` APN �007__� REF# <br /> 1. 4p Q3 Yv EXP.DATEDR# <br /> �5' !� <br /> (Applicant N_` e VALID <br /> Lac. 1 l y q t,$Q STREETq x O <br /> pOX DRIVEWAYS:# S�3c� �a,►v <br /> AREA QUAD Q <br /> (Mailing Address) Q TYPE 712E UAD , <br /> crS I S O FORMS tvr v <br /> X-2 <br /> NOTES f W�C/ eLJ_C� <br /> (City, State,Zip Code) <br /> Zog- 943- Lpg1 Z <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> s' <br /> Ox Fnk� w� <br /> The undersigned hereby applies for permission to excavate,construct <br /> the N o rZ-�t� side of and/or otherwise encroach on Court Hi <br /> of—��eczs�,► —�K <br /> approximately_ S 04 ry Highway Right-of--Way on <br /> — feet/mile e S� <br /> o by pertorming the following work(description of work): <br /> e t uT baa <br /> Work will commence on or about <br /> y- I -� <br /> I, the undersigned,certify that I am the owner of they respectivePropertyfor approximately. <br /> work described above in accordance with the rules and regulations of San days. <br /> ,or am qualified to represent the owner and agree to do the <br /> Joaquin County and subject to inspection and approval. <br />"Signature of Applicant-Title C m b'`?'%8 <br /> E1PU&SV WKIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC Stac \�a Z <br /> rolAe, Date <br />