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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin vu Ll <br />Department of Public Works <br />CoM�__ <br />(Applicant Name) <br />(Mailing Address) <br />L.oT�I/1..6i � Gr4 953 3 b <br />(City, State, Zip Code) <br />Z /3-4%877 <br />(Area Code - Telephone Number) <br />may <br />�� t; ATT /4 tm JN <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Hig Right-of-W�y� <br />the �N Wer side of N • w i �SO►� (w� Y approximately ____� fee ile E S <br />of SZEvoA2T" ST o Cac r,QAJ�, by performing the following work (escdption of work): <br />4?0af: �vN _ CXVts i ul n.dTy v�4Ur� To Z Z 75 N• r^�/�So rJ [vi <br />Work will commence on orabout — for approximately 9 � days. <br />I, the undersigned, certify that I am the owner of the respective property, or am qualified to repre <br />sent the owner and agree to do the <br />work described bove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />x4� - /0�0- / <br />-2:13ifigqlaure of Applicant - Title Date <br />OFFICE USE <br />ONLY <br />J0B# <br />REF# <br />APN <br />CR # <br />EXP. DATE <br />20 <br />VALID <br />0 <br />20 DRIVEWAYS: <br />STREET <br />ZvAy <br />AREA <br />A) QUAD <br />Aly ' <br />TYPE <br />ut? /A)s;,A <br />z <br />FORMS <br />SS��✓w. 29 <br />NOTES <br />�T <br />a <br />Guy <br />�� t; ATT /4 tm JN <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Hig Right-of-W�y� <br />the �N Wer side of N • w i �SO►� (w� Y approximately ____� fee ile E S <br />of SZEvoA2T" ST o Cac r,QAJ�, by performing the following work (escdption of work): <br />4?0af: �vN _ CXVts i ul n.dTy v�4Ur� To Z Z 75 N• r^�/�So rJ [vi <br />Work will commence on orabout — for approximately 9 � days. <br />I, the undersigned, certify that I am the owner of the respective property, or am qualified to repre <br />sent the owner and agree to do the <br />work described bove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />x4� - /0�0- / <br />-2:13ifigqlaure of Applicant - Title Date <br />