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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 01 111 ?0 <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, state, zip Code) <br />(Area Code m Telephone Number) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS/�,,✓, <br />NOTES <br />OFFICE USE ONLY <br />//Gcbj REF # <br />CR # <br />b to <br />Z TO G so DRIVEWAYS: <br />QUAD //E <br />$e g r3ati PF r <br />�z9 <br />" SAk; i44. e9W0M6Ay& " <br />for approximately q(L_ <br />days. <br />I, the <br />undersigned, certify that I am the owner <br />of the respective property, or am qualified to represent the owner and <br />agree to do the <br />work <br />described above in accordance with the <br />rules and regulations of San Joaquin County and subject to inspection <br />and approval. <br />Skeich (Detailed plans may be submitted) �2C3(�-� W L <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach <br />,Qn_County Highway Right•of-Way on <br />the Wt?j� side of ti 11�C>✓Q� 1RfcN(`,1k uu�• approximately _ !.( mile <br />of W1 Ebw iY2• UlG ll2D by performing the following work (description of work): <br />Work <br />will commence on or after <br />for approximately q(L_ <br />days. <br />I, the <br />undersigned, certify that I am the owner <br />of the respective property, or am qualified to represent the owner and <br />agree to do the <br />work <br />described above in accordance with the <br />rules and regulations of San Joaquin County and subject to inspection <br />and approval. <br />SibriaFure -- <br />