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f <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: • <br /> Date _ ` J ' OFFICE QSE ONLY <br /> To. San Joaquin County JOB is 7'S Lc--) REP # <br /> Department of Public Works APN Cg• # <br /> EXP; DATE (:>I?— <br /> AW- <br /> 1"j� t C Dn-\ &C L� c- VALID 9-LI:2.61no DRIVSKAYs s <br /> (Applicant Name) t STREET + <br /> 3 UU Z—: �CrGr 7 ,��le. ARPE <br /> QUAD � — <br /> TYPE e , <br /> (flailing Address) FORMS W . (Z2q <br /> c[ S a [ 0 NOTE <br /> (City, State, Zip Code) <br /> 201 '-12L1, Ll3 �y <br /> (Area Code - Telephone Number) <br /> sketch (Detailed plana may be submitted) <br /> A fy4 uco -DLUL'- . <br /> S S q <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encja" on County Highway Right-of-Way on the �il-•k 4 S'04->�side of <br /> 2(_ � I�CJC approximately feet/mile S AST <br /> of by performing the <br /> following work (description of work) : /17,9f Cp 7- /ST GTS y <br /> pt4C.e_ 4� FSx <`1g' UAU- I v mf e-- L(F1dQr �-y01Q- <br /> Work will commence on or about 1-? tZ� for approximately <br /> 2o days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval, <br /> 2_.-- <br /> Signature ofApplicant - Title V Date <br /> �JL+'E1 PU?RRSCML i5i;0) <br />