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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5-- 3 - 13 OFFICE USE ONLY <br /> To: San Joaquin County JOB# "- dD REF# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE 111610 -1 -1 <br /> V E R l Z lV 61-- C,4,1 1 AIC, VALID DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 42f kA/, C—r.i,,!-j-1� s"7'= AREAQUAD <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) A* /fit/ <br /> ZD9 - ZS9 - CJ36-5 4964� D� e <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ,E :`3 7`7-;q zf/-f z.2D PP/N T 1 OF 1 <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encro ch 2Dounty Highway Right-of-Way on <br /> the ECJ 5T side of �1/k PIY Y` R D, approximately �0 feet/ <br /> of IV W yr / E O • , by performing the following work(description of work): <br /> DIEE-C/ / AIA /SORE P✓C FPDM N! EW rND 1,40L/-E '4DLIl4r)----A/ 7- <br /> TD f X/S 71L VF 'r ',.%f�A f` r ; Tr`r NQ R i/-j TQ 5'TA) T , <br /> C1.LIrgR //A R/G1-1i D,�c LAZA l DN 7-HESn/>Tf-7/ S1�F <br /> 14/614IAIA Y i Z. Q , . <br /> Work will commence on or about G -/a - 13 for approximately 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 /> 0O <br /> Signatur of Applicant-Title COate <br /> E1PUB&SV.WKOAASTERasENCROACHMErrraQuernPPUCAnoN.Doc(01M) <br />