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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: /� / L} <br />Date �7 � <br />To: San Joaquin County <br />Depa71JAbc. <br />t of Public Works <br />C�M4A' 7W <br />(Applicant Name) <br />/2657 5- MANiZ��'! z� <br />(Mailing Address) <br />3 0 <br />(City, State, Zip Code) <br />1"25J 7&" X877 <br />(Area Code - Telephone Number) <br />T1iRrSDrcrf av <br />Sketch (Detailed plans may be submitted) <br />Ser, 'W'4 (-Wgb1 <br />The unders <br />i ned hereby applies for permission to excavate, <br />ro eaQ7 Arm Sf <br />and/or otherwise encroach on County Hioht*yRfight-of-Way on <br />of <br />_approximately /PO ile�dST" <br />u , by performing the following work (description of work): <br />.-)r 717L&6 &4/6 CA3L6 W)'c L - <br />Work will commence on or about LZ�9 _ " far approximately , o days. <br />I, the undersigned, certify that I am the owner of the respective properly, 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 />i�� rZva� p. oP 9-2 y <br />/4 <br />� Signature ofApplicant -Title Date <br />OFFICE USE ONLY <br />JOB # <br />//OSS <br />REF # <br />APN <br />CR # <br />EXP. DATE <br />VALID <br />? n ZoI <br />TfoS 1v <br />DRIVEWAYS. <br />STREET <br />lor <br />AREA <br />Srmeeraa/ <br />QUAD A6 <br />TYPE <br />EQrAG <br />/.voek <br />' <br />FORMS <br />tt/N/ <br />NOTES <br />" $ <br />dots <br />[',KIrr it[. <br />T1iRrSDrcrf av <br />Sketch (Detailed plans may be submitted) <br />Ser, 'W'4 (-Wgb1 <br />The unders <br />i ned hereby applies for permission to excavate, <br />ro eaQ7 Arm Sf <br />and/or otherwise encroach on County Hioht*yRfight-of-Way on <br />of <br />_approximately /PO ile�dST" <br />u , by performing the following work (description of work): <br />.-)r 717L&6 &4/6 CA3L6 W)'c L - <br />Work will commence on or about LZ�9 _ " far approximately , o days. <br />I, the undersigned, certify that I am the owner of the respective properly, 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 />i�� rZva� p. oP 9-2 y <br />/4 <br />� Signature ofApplicant -Title Date <br />