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PLEASE PRINT: <br />APPLICATION I OR ENCROACHMENT PERMIT <br />#Uol1(A <br />Date I? 211% <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />12�e$1 S - MLCr c� RSI• <br />(Mailing Address) <br />1,PcCkhR-uw � o1533y <br />(City, State, Zip Code) <br />AD -00 L 1(j <br />(Area Code • Telephone Number) <br />Sketch (Detailed plans many be submitted) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highw Rightl <br />of-Way on <br />the side of �, 1N�,12- RVQ approximately 2.Cn ee tle-�� <br />of C;IFI by performing the following work ( escdplion of work): <br />Work will commence on or about ovz�izo far approximately days, <br />I, the undersigned, codify that I am the owner of the respective property <br />, or am qualified to represent the owner and agree to do the <br />work descdbed above in accordance vrith the rules and regulations of San Joaquin County and subJect to inspection and approval. <br />K%Mjj@MMz=fFn1 mini <br />12,2'1�yU <br />Data <br />OFFICE USE ONLY <br />013# <br />//OSS REF # <br />APN <br />CR # <br />EXP. DATE <br />s IS <br />VALID <br />r y T' <br />DRIVEWAYS: <br />STREET <br />'r" f FM ov a- # A40)!L&e 09vp. <br />AREA <br />Mmorran/ QUAD Ad <br />TYPE <br />73o¢�srs) f .Qat 6n&4 PLS! <br />h4 <br />FORMS <br />�w.�/��yS <br />NOTES <br />g Dm t3 <br />of-Way on <br />the side of �, 1N�,12- RVQ approximately 2.Cn ee tle-�� <br />of C;IFI by performing the following work ( escdplion of work): <br />Work will commence on or about ovz�izo far approximately days, <br />I, the undersigned, codify that I am the owner of the respective property <br />, or am qualified to represent the owner and agree to do the <br />work descdbed above in accordance vrith the rules and regulations of San Joaquin County and subJect to inspection and approval. <br />K%Mjj@MMz=fFn1 mini <br />12,2'1�yU <br />Data <br />