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10/143/2013 10:22 2099483982 ARCH ROAD CONSTRUCT PACE 02!05 <br /> APPUCATiON FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� .� �.0\3 OFFICE USE ONLY <br /> To: San Joaquin County JOB# /jDDpS" REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 IS 1? <br /> VALID i0114113 fO /1115-113 DRIVEWAYS: <br /> (Applicant Name) STREET p to ' <br /> t,. AREA QUAD . <br /> �: 1 i TYPEirJ.rZ <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) C 1) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 4�1 J'r CY•-P 1'' `^ �'r^C �'� (?J L1 <br /> The uncle igned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the � 5 side of Iet6 AN approximately 1220 1 feet/mile <br /> of. 'P `'[. �' ','S by performing the following work(description of work): <br /> AA M4n <br /> t � <br /> L <br /> Work.will commence oh or about : l 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 /> wor .described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> o A za13 <br /> SiTh6tuirfe of Applicant-Title tate <br /> crr— r. S <br /> MICEMPr SMW.UClFR6Al1P11M.VMN/\ITFRMOCRQACHWWPSf&VAPPlM1TMWC fM3) <br />