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Pit go <br /> „ <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date m i-�) op o i'"? <br /> r OFFICE USE ONLY <br /> To: San Joaquin County JOB# '75665Z-5- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID /2 fo 113 DRIVEWAYS: <br /> ` (Applicant Name) STREET P.1As'f2a u�C _tZ D. <br /> ,( ,1 �- 1 AREA Load QUAD <br /> I � yt-yF'I�-P { TYPE <br /> (Mailing, (� °� FORMS �r5 -29 <br /> ... � P 0"1 ` Ltd NOTES <br /> (City, tate,Zip Code) <br /> Wtdol Sa,�ic � (bJQ 760 -3342 <br /> (Area Co&l-Telephone Number) <br /> Sketch(Detailed plans may be submitted) f�1 Wo <br /> Cie <br /> P \) <br /> The paersigneanerebyapples r ermi.ssign excavate,con ct and/or otherwise encroa�h on County High Rightrof Way n <br /> the side of— � r l`- Pproximately fee He 1,4&S <br /> of by performing the following work escription of work): <br /> � c L <br /> iil�tzl1—� '_ _ UU Lt <br /> Work will commence on or about�- 4 C C. 9-D11"11 " J �-- r `dor 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 /> U 3 0� viz <br /> Signature of Appli ht-Title Date <br /> LIPU&SV.%%'WAASTERPSFNCROACY.MEUT PERMT APPLICATION.DOC(01108) <br />