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177611 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: /� <br />Date ./O— qJ / <br />To: San Joaquin County <br />Department of Public Works <br />Zolw4 sT Z e//E)s �y <br />pplicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />49Z5% 7e3 -4/P177 <br />(Area Code - Telephone Number) <br />may <br />The undersigned hereby applies far permission to excavate, constmct andlor otherwise encroach on County Highwa R{ght-of-Way on <br />the EST. side ofcu ^9 F � approximately ee ile-�ouTN <br />of M / , by performing the following work cription of work): <br />y0 �x� vr4Tl To Ti4!'6 T�c_A�& • - <br />Work will commence on or about � / for approximately 3 o days. <br />13 the undersigned, certify that I am the owner of the respective property <br />, 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 />rno iT c"( Qz>1 wTop. fa- 9 / I — <br />u e of Applicant • Title Date <br />OFFICE USE ONLY <br />JOB# <br />&06os REF# <br />APN <br />CR # <br />EXP. DATE <br />2 / Lo <br />VALID <br />// /�/_ 0 Z// ho DRIVEWAYS: <br />STRI <br />AREA <br />�rA .v Q+>, <br />QUAD^/� <br />TYPE <br />fid PEAL lj/at� ?dArF�G Ld=p✓ <br />FORMS <br />NOTES <br />The undersigned hereby applies far permission to excavate, constmct andlor otherwise encroach on County Highwa R{ght-of-Way on <br />the EST. side ofcu ^9 F � approximately ee ile-�ouTN <br />of M / , by performing the following work cription of work): <br />y0 �x� vr4Tl To Ti4!'6 T�c_A�& • - <br />Work will commence on or about � / for approximately 3 o days. <br />13 the undersigned, certify that I am the owner of the respective property <br />, 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 />rno iT c"( Qz>1 wTop. fa- 9 / I — <br />u e of Applicant • Title Date <br />