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PS -2101564 <br />v <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date d / i )'kQo2 <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />a� I <br />s rM4 6A— <br />(MaUhg Address <br />Nuyld tole. 04 q 6WO1 <br />(City, State, Zip Code) <br />530 3(>?3-05-74 <br />a (Area Code - Telephone Number) <br />\Aae.42 o -y to Ylaiy? e-c)M <br />ai ddress) <br />Sketch (Detailed plans may be submitted) <br />See- 0-G{ae ked <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />110005 REF # <br />CR # <br />;/512921 88: X2921 <br />TO DRIVEWAYS: <br />Hwy 99 Frontage Rd <br />Stockton QUAD <br />Driveways &Trench <br />X8 4°-29� cls Poli <br />Special Conditions <br />The nder�igned�eby applies for permission to excavate construct nd/or otherwise encroach o County Highway Right -of -Way on <br />the S sideof Srda o -F Clq -�voJf�oae-� approximately (000 <br />ofI , by performing the following work (description of work): <br />c7 N dy'tycu��-c Gu.r b �k G <br />commence on or after <br />approximately <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 />r of Applicant - Title Date <br />v sat rzs¢xaroocxuaxrruuarnvrvcnnox o=rcam� <br />