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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date l d - 1 & - 1 <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />26 5 • �Z <br />(Mailing Address) <br />Z_I&Al f�P4 r-, �.S__3. 3 0 <br />(City, State, Zip Code) <br />Zs 7a-�, - Ll e7 7 <br />Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />The undersi �+�ned hereby applies for permission to excavate construct and/or otherwise encroach on County Hi Right -of -Way o <br />the AA:,-7Tside of �., � TUR. _— approximately ; fee ile 190UTN ►I_V <br />of DV& E13&L- rTo►J , by performing the following work {description of work}: <br />Work will commence on'or about for approximately C20 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 />uA�OIL <br />Signature of Applicant - Title <br />4�CCHtpAiSFiM099A-F7WALnBSvWMMTMPSOKM5CHKWPEMIAPMCAmn000 (0571 <br />Date <br />OFFICE USE ONLY <br />JOB # <br />REF # <br />APNCRN <br />EXP, DATE <br />� l 7.0 <br />VALID <br />IZ 7a L 0 r L4. DRIVEWAYS: <br />STREET <br />?W6gojGEE. Rzo i <br />AREA <br />S-?zceit QUAD N-6- _ <br />TYPE <br />_" n.A P rl Gari: Raj- CA-%: <br />FORMES <br />NOTES <br />0, <br />" 5 4 LCb kX <br />The undersi �+�ned hereby applies for permission to excavate construct and/or otherwise encroach on County Hi Right -of -Way o <br />the AA:,-7Tside of �., � TUR. _— approximately ; fee ile 190UTN ►I_V <br />of DV& E13&L- rTo►J , by performing the following work {description of work}: <br />Work will commence on'or about for approximately C20 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 />uA�OIL <br />Signature of Applicant - Title <br />4�CCHtpAiSFiM099A-F7WALnBSvWMMTMPSOKM5CHKWPEMIAPMCAmn000 (0571 <br />Date <br />