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RECEIVED <br /> APPLICATION FOR ENCROACHMENT PERMIT APR A 2012 <br /> PLEASE PRINT: Ir REISNO <br /> I <br /> OMD/DPD <br /> Date 2112 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXF.DATE <br /> `^ .� r <br /> l �r u '�(1 -��� G VALID zqQ Z 2 y 0 y l f /2, DRIVEWAYS: <br /> (Applicant Name) STREET �:4 C <br /> AREA Lo <br /> TYPE I i SQUAD t C t <br /> (Maiung AaaressJ FORMS SS WW ? <br /> LA C1.�,� � NOTES <br /> (City,State,Zip Code) <br /> 2,9 Lt-7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> P��hTe. qv-<4 �6ffe,,\1 kOOi c�- r,, Q1C�5kr-- <br /> i qa c. c nAmk OQ� a Cw-)*v C--VLCn Aq'-(�w► Qom. <br /> o <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the A QCA.�' side of © approximately 0, feet/mile <br /> of , i('� by performing the following work(description of work): <br /> 5ee-- f6&QZ <br /> Work will commence on or about ►': 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 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 /> 112- IL <br /> Signature of plicant-Title Date <br /> E:IPUBSV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.000 (01106) <br />