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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 'DN CS 3, 2-012— OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN ria YCR# <br /> +� ,,,{ -� I <br /> EXP.DATE <br /> i� 61 TJ D04 V r� U AI I-IC-17 VALID �3`TO t13 DRIVEWAYS- <br /> EP Name) STREET SZD + c�rJ � cki <br /> c5s-o .�4"I two'l/C-�►. Rco TYPE - R6PI.AC Ni Aw%rV <br /> (Mailing Address) FORms o2-0- <br /> NOTES <br /> (City,State,Zip Code) <br /> / � � � 2. 94/ <br /> (Area Code-Telephone Number) <br /> Sketch-(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way o <br /> thet- side of )V !7at,A-- r approximately �� Z- feet/miles P2�e�¢e+v <br /> -ef 2 mob` 5 by performin the following work(description of work): <br /> Gi h d C.Q 0- r C i e C U I -e�l/�©t <br /> ail 0,b 5,00° LV& <br /> Work will commence on or about4AI l 2 0y3 for approximately .17—D 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 /> Signature of Applicant-Title LL D..�/ra{te C <br /> ESPIISSV.WKVMSTERPSIEIICROAOHWfT PEW APPMATIOH.DDC(0108) ''/ �' <br /> � f /IfJ'IfC <br /> Rei ► + r a" +f�N �or VV r����rffff//��''I111f1 <br /> Y <br /> I�roJeC�. Lf �����1/2.. <br />