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P5_Xoaol41 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date k-- 07 — % ! <br />To; San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />7,6K7 S . I 4wc-'1 <br />(Mailing Address) <br />TAI2,08 c,4 9f�-3 30 <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) SGC— <br />A -TF 4 (-H <br />The undersigned hereby applies for permission to excavate construct and/or otherwise encroach on County Hightw Right -of --Way on <br />the !NO { / side of 4U �N 1� "-'s � ap�proximately 100 =lie W <br />of F!Qi&?c-H CA M r', by performing the following work (description of work); <br />C- L6o �_N 7� d E sgF 2,�dIz�J 3 o R --Z ©� - <br />-_,-�r�� Cid". J'' ✓ S��✓ r , <br />Work will commence on or about 1 xro 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 />e��Je-' 8.9 / 9 <br />D�Sigfiature of Applicant - Title Date <br />lF 5CE7�PtALSEaYLE9RERiC.�l4PV0 SV FY�l4.15TEA PSEhCRC�CkUE�if PERsa�T APF�KAllptl POC IPvt�� <br />OFFICE USE ONLY <br />JOB # <br />RBF # - <br />- - - <br />APIV <br />- ------ CR # <br />EXP. DATE <br />VALID <br />TO DRIVEWAYS <br />STREET <br />_ <br />XD_ <br />AREA <br />QUAD NL,) ' <br />TYPE <br />A6CIAL. waek Bae,, a04Ap;4" <br />FORMS <br />?rc! <br />NOTES <br />A L- tJs •. <br />A -TF 4 (-H <br />The undersigned hereby applies for permission to excavate construct and/or otherwise encroach on County Hightw Right -of --Way on <br />the !NO { / side of 4U �N 1� "-'s � ap�proximately 100 =lie W <br />of F!Qi&?c-H CA M r', by performing the following work (description of work); <br />C- L6o �_N 7� d E sgF 2,�dIz�J 3 o R --Z ©� - <br />-_,-�r�� Cid". J'' ✓ S��✓ r , <br />Work will commence on or about 1 xro 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 />e��Je-' 8.9 / 9 <br />D�Sigfiature of Applicant - Title Date <br />lF 5CE7�PtALSEaYLE9RERiC.�l4PV0 SV FY�l4.15TEA PSEhCRC�CkUE�if PERsa�T APF�KAllptl POC IPvt�� <br />