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T � <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date g -: )f OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3po5z-- l0 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2013 <br /> e aw f-7)zG li VALID -27-2013 TO - i- DRIVEWAYS: <br /> (Applicant Name) REET Goh a �n ' <br /> AREA QUAD <br /> (2 � c�J`.�.a a f �' nvy•� 1 c4 RM i3zb TYPE ' 0,e- <br /> (Mailing Address) FORMS SyG�a 5LodS2GAt oV-3yoo <br /> NOTES <br /> _ 11 1`/5'83 <br /> (City,State, <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> �6�sos7y <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Ca,S side of R-C— approximately /. feet/nW lh r�of a! i)aL r�c��T_a/�,� .c�.—ISS�,�Eby performing the following work(description of work): <br /> a�Y shy L <br /> z, an r f nfi (/s„I fi d',,1/ 0 Nr,✓ <br /> Work will commence on or about—:!re,-d— 5 for approximately ql-) 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 /> f <br /> Signature of Applicant-Title Date <br /> I <br /> E:4'Ue.5V.1YfMNSTERPS'ENCROAUU.'EIR PERt:JTMPLICATI011.DOC)OiNB) i <br />