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APPLICATION FOR ENCROACHMENT PERMIT <br /> PVAE P NT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County I JOB# j t O C 05 REF# j <br /> Department of Public Works APN CR# <br /> EXP.DATE Q1 Its <br /> COAACA VALID 5 hzj 13 Tb !0 13 DRIVEWAYS: <br /> (Applicant Name) STREET h'.44 UA/ <br /> AREA 40mieop QUAL) 15e, • <br /> •-� E 'r1�M d A� TYPE RoLts,5 "s <br /> (Mailing Address) FORMS -Z <br /> i NOTES I <br /> A 5�� 0 <br /> (City,State,Zip Code) <br /> ( -MQ:C2S'v� <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 3 2g OF-- So R-E ©w A RL-AM <br /> 2-:2- 05- W M- o AAC,K-MW LAY AV 5 <br /> Ac&es5 POLE L--EWE (WHOM-MZ) OM Fi AN-A V QD, <br /> AND <br /> AA5-11ZC-E4� t13730 I0700 i5?. HARLAN tom. <br /> The undersigned hereby applies for permission to ate,construct and/or otherwise encroach County Hig Right-of--Way an <br /> the AST side of . S•.A1CK2QLFY approximately fee ild- . <br /> of_ Cie-TN ,by performing the fallowing work ription of work): <br /> TR OF: b2LE ON 5 , LIRLW <br /> V11 Lt._ D F_ <br /> Work will commence,on or about T for approximately 5' days. <br /> I,the ur4nigrted,certify that I am the owrer of the res m&e pmpeq,or aim qw-i to€event tine owe WW agree to do the <br /> work described above in wzvdw=wdh the noes and requWkns of Senaeqtm Cou*and sL4W to irqectitm and awc*L <br /> IN <br /> .Tide <br /> �y �1 <br /> E.'�'.et-gym xof3�f7IFPtscDOC��,, <br />