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J'170149 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />G'�MI<.�/GN2ish In �r <br />(Applicant Name) <br />1260-7 <br />(Mailing Address) <br />G �TNev�� c,,o 4 53. 0 <br />(City, State, Zip Code) <br />X49 7&"2 - IS 77 - <br />(Area Code -Telephone Number) <br />plans may be submitted) <br />�t;r A'IfN <br />The undersigned hereby applies for permission to excavate, construct and/or othervrise encroach on County Highw Right -of -Way on <br />the W �sr, side f �2�C-w �D - 9 �._ _._,-_ approximately � D ee lie _yO,Q7-lf <br />of � . �L 6 GOA 1 by performing the following work ascription of work): <br />Work will commence on or about farapproximately �D days. <br />I, the undersigned, certify that! am the owner of the respective propert <br />y, 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 />7 'W1zh) r G 162 - ?- / 9 <br />Sign of Applicant - Title Date <br />OFFICE USE ONLY <br />JOB # <br />//QQJS REF # <br />APN <br />CR # <br />EXR DATE <br />i Zo <br />VALID <br />B 2 t Zu <br />DRIVEWAYS: <br />STREET <br />AREA <br />TYPE <br />FORMS <br />Loa�� QUAD 416 <br />Ae�:oG Wim- 7�i AafrG <br />5/i��✓ <br />Cruz <br />DE✓'�E <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or othervrise encroach on County Highw Right -of -Way on <br />the W �sr, side f �2�C-w �D - 9 �._ _._,-_ approximately � D ee lie _yO,Q7-lf <br />of � . �L 6 GOA 1 by performing the following work ascription of work): <br />Work will commence on or about farapproximately �D days. <br />I, the undersigned, certify that! am the owner of the respective propert <br />y, 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 />7 'W1zh) r G 162 - ?- / 9 <br />Sign of Applicant - Title Date <br />