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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- <br /> Date 4 S" - l Ci 231tio►Z <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# p <br /> Department of Pubic Works APN REF# <br /> EXP.DATE CR# <br /> CN_ets ePY �C�t rA6)- ____ <br /> VALID 7 <br /> (Applicant Name) STREET L T S 1L DRIVEWAYS: <br /> 62Z AREA ,QUAD <br /> `�Te ���QS L� A '7 TYPE <br /> 011 <br /> (IVlarimg AiI <br /> ddress) FORMS W , <br /> S7TOrU. C iU q SaO� NOTES <br /> (City.State,Zip Code)- — <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pans may be submided) <br /> SEE A-MA C46b <br /> 5J23rzoiZ-4- NREV PtDD�'T'IOIVAL S(.O'f of goRE F <br /> 60RE P1T �M <br /> (5ovr+-y oc ARcK RD.) �v C.zTr of s7-oc.�er'ot� <br /> BOVN�W, WEST' OF PROPOSED TARGET <br /> (6SOO A Rv) ADoa,Ess <br /> S� A-MA,:Heor <br /> oThe undersigned hereby apples for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> fiLls 'side approximately �tb <br /> - -k- b - feet/mild _ <br /> T Z y Performing the following work(description of workk <br /> Tc.a o �"fN <br /> God 7 Cf4T _ <br /> aC <br /> UVork NO commence on orabout <br /> for approximately <br /> I,the undersigned,certtfy that I am the owner of the respective properly, representthedays. <br /> work described above in accordance with the rules and egulations of SnJoaq qualified <br /> to and subject to inspection and approval agree 10 do the <br /> 4 �T Coate//L,�4 ��S- ! <br /> qVnatulre—of Applicant_Title <br /> EW95y PBWAFRCAn=. <br /> Date <br /> pt" <br />