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APPLICATION FOR ENCROACH ENT PERMIT <br />PLEASE PRINT: <br />Date k K2—J2 <br />To; San Joaquin County <br />Department of Public Works <br />c -c k.�rico <br />p <br />(A cant Name) <br />1 2�xsl -G-- MLtn <br />(Mallinrg Address) <br />(C4, State, Zip Code) <br />fQl9,VT ) 1-01ot_q-ia . <br />(Area Code - Telephone Number) <br />%-A <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB # //49W5- REF # <br />APN CR # <br />EXP. DATE <br />VALID Z T0 DRIVEWAYS: <br />STREET <br />AREAQUAD <br />TYPE G <br />FORMS <br />NOTES Alpfr o <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County Highway Right -of -Way on <br />the 171kt 'i side of YL -Gluey PA . approximately W_____ eewle—. ' <br />of Tx—�C-N. , by performing the following work (description of work); <br />commence on or after <br />for <br />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 />r LFaaus a in41L,rhsV0M0Q1M(TPERLer RvuG31011dx})&WI <br />Qd � 9-0 <br />Date <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County Highway Right -of -Way on <br />the 171kt 'i side of YL -Gluey PA . approximately W_____ eewle—. ' <br />of Tx—�C-N. , by performing the following work (description of work); <br />commence on or after <br />for <br />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 />r LFaaus a in41L,rhsV0M0Q1M(TPERLer RvuG31011dx})&WI <br />Qd � 9-0 <br />Date <br />