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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9111 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> /' EXP.DATEf l2 <br /> (�QMLAST- VAUD TO D lS l2 DRIVEWAYS.- <br /> (Applicant <br /> RIVEWAYS:(Applicant Name) STREET ,d:%4- W <br /> AREA Ly9 QUAD <br /> 6SOS -rA.M dSHANMR. Da . TYPElieu- oLES <br /> (Mailing Address) FORMS ��i>f,✓, X-29 <br /> NOTES <br /> t,.1crDJJ CA 957119 <br /> (City,State,Zip Code) <br /> s0SO-0y-053 D <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submit�d} <br /> � 07 ysg �2�'yy2 aIQPolti-RD. N1ET�o-G� <br /> The unders ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the W T side of . VA! RD. approximately 2 e mild <br /> Of 4 .by performing the following work(description of work): <br /> (VI ED w- 11" OF- 50PF— -TQ TN'OTALL Z� HDPE r-numr.ET, 6IFTLyf-EN E.xTST=& <br /> LII TfY fte!5, SHOULOEZ CL06V RE REQV=iZE.fD , ALL Ltypk Wtl1- BE <br /> -WI-NTN 10' l=IZo m E.O. P. SEE �,-r►-a{u Ec. <br /> Worts will commence on or about .7/7,01-Z for approximately h dabs. <br /> 1,the Wined,cerrdy that I am the ovmer of the respective property,or am gualified to represent the oar and agree to do the <br /> wcxk described above In accordance v tth the rules and regulations of San Joaquin County and subject to irspeckon and approve t. <br /> of tea-r Date <br /> ETtl�p P9rffIF4L�OaDOC Irl <br />