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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 01�'yi1'Jp <br />r <br />To: San Joaquin County <br />Department of Public Works <br />NAME I Se NCO <br />(Applicant Name) <br />121PY'1 S MANU-6`i Vd . <br />(Mailing Address) <br />(City, State, Zip Code) <br />Iq 25 M I) ' C l.( --'I 6 <br />(Area Code - Telephone Number) <br />may be submitted) <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on C my Highwa Right -of -Way on <br />the IVb`R'�1'c side of S1iUU� �L approximately �(nile <br />of by performing the following work (description of work): <br />"60 11) 1P1,Pcl`,t, Fft(-E t rr 6.1,yst,r irayw\ i;c , Bum DF�ttNo �;k <br />Work will commence on or about for approximately q(7 days. <br />I, the undersigned, certify that I am the owner of the respective pro <br />perty, 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 antl subject to inspection and approval. <br />M OFFICE USE ONLY <br />013# <br />1/0605 REF # <br />APN <br />CR # <br />EXP. DATE <br />iio <br />VALID <br />2dq Zo 0 eo/ 2-o DRIVEWAYS: <br />STREET <br />gra a 1z Pt o <br />AREA <br />QUAD yy rte! <br />TYPE <br />7S4e1 OrY5 <br />FORMS <br />NOTES <br />k <br />dP 914PAVT- aP-dA ej A16 Mor rNEAsr <br />Ceti- MEl�SSAQ <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on C my Highwa Right -of -Way on <br />the IVb`R'�1'c side of S1iUU� �L approximately �(nile <br />of by performing the following work (description of work): <br />"60 11) 1P1,Pcl`,t, Fft(-E t rr 6.1,yst,r irayw\ i;c , Bum DF�ttNo �;k <br />Work will commence on or about for approximately q(7 days. <br />I, the undersigned, certify that I am the owner of the respective pro <br />perty, 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 antl subject to inspection and approval. <br />