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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: 1 <br />Date 1I23{w <br />To: San Joaquin County <br />Department of Public Works <br />CoMC�+sT � StiFN CO <br />(Applicant Name) <br />V2LQS'1 sI�AL� • <br />(Mailing Address) <br />(City, State, Zip Code) <br />025 2 o- clo F <br />VAP reCode - Telephone Number) <br />L+oc�'r W Bu rr,). r 0 M <br />(Emelt Address) <br />may <br />The undersigned hereby a <br />the �� side <br />unty <br />Of A14M <br />JOB# <br />APN <br />P. DATE <br />VALl <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />//dmf REF <br />CR # <br />i <br />TO DRIVEWAYS: <br />oeO, <br />gr in) QUAD AV <br />%4j~ /aAJTO�- �e✓�lEL <br />Ss/t✓� / <br />5 G Om <br />n <br />Joaquin Couniy <br />and subject <br />to Inspection <br />and approval. <br />G�s�l <br />For permission to excavate, construct and/or otherwise encroach nn CoHighway Rightof-Way on <br />PcU6Ci�v '¢,/� • approximately ee mile <br />by peftming the following work scription of work): <br />Work will commence on or after for approximately al Q 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 $42 <br />0 'R <br />MIS <br />INVAR <br />n <br />Joaquin Couniy <br />and subject <br />to Inspection <br />and approval. <br />Signature of Applicant w Title Date <br />