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doxAbI <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date ml z1JI2U <br />To: San Joaquin County <br />Department of Public Works <br />lF rtrt <br />Applicant Name) <br />MprrTrW-�y hof <br />(Mailing Address) <br />I,�fifi�YLU`Q ('*1' Gl ci�i?� <br />(City, State, Zip Code) <br />n� �5 <br />Area Code • Tete hone Number) <br />"N01 X & NCO. 4211L� <br />(Email Address) <br />Ske��jjfc(�h',,(Detail�ed{pyl�an�smay�be submitted) <br />The undersigned hereby applies for permission tc excavate, construct and/or otherwise encro <br />JOB# <br />APN <br />EXR DATE <br />VALID <br />STREET_ <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />//AODs REF# <br />CR # <br />fs <br />o T iS 0 DRIVEWAYS: <br />�rGk t4FI^l QD <br />QUAD AO <br />C CA�1i'BG-CES <br />iJ(LS' <br />ach on County High Right -of -Way on <br />the Sl'IUT� side of F �fi(LCiMRr+ LIQ approximately ee mile <br />of APPjl&IUAt i (2 T). by performing the following work soription of work): <br />Work will commence on or aper for approximately 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 of San Joaquin County and subject to Inspection and approval. <br />Ar iJAI4 (K <br />��..�' <br />signature of Alipllcan6 �Tftle- Date <br />