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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I f���(�- OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / 1 <br /> f ATA*V VALID ,Z g z- TO 3 3 DRIVEWAYS: <br /> (Applicant Name) STREET fjy� c- z ' <br /> AREA r<;(4�-,rj QUAD �. <br /> TYPE i-� 1^.141-t- <br /> (Mailing Address) FORMSG✓iV <br /> NOTES <br /> (City,State,Zip Code) <br /> T*L-#tvi) �;'111 -- SCP <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise qncroach on County Highway Right-of-Way on <br /> the 40t fW side of VJ fee _ <br /> of okJ ,by performing the following work(description of work): . <br /> cp!j!�ffta flymy WAl._ oo vol-lez1hiic, soy. Gtr .L v .. Cui t <br /> Work will commence on or about t for approximately !IF 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 /> �s 1 ��J 1,2, . <br /> Signature of Applicant-Title ate <br /> E:IPU&SV.WMMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC(01/08) <br />