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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINL (� L <br />Date /0—/V- <br />To: <br />0— l7 <br />To: San Joaquin County <br />Department of Public Works <br />Goy-r�osr G�� Q�s Ty <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />9zJ 703- V8'7-77 <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />��es. 4-1-7w cN <br />4 1&05T oi; purr �;- 'OaAk' (5 w,-- H I tj -rA6 ctry 6ie- 6004 <br />The undersigned hereby applies for permission to excavate, c nstruct and/or otherwise encroach on County Nigh Right -of -Way on <br />the Al / side of 6 . C-1'�c�E�' d0i' L AI approximately / fe iie,�ST <br />of T{xGe y , by performing the following work description of work): <br />A i c Go 4- -AI' C, <br />-T'� _�- n>- . r� �U.r 1GYt �1� lu}7 �.5 U -7"r. T1Q -4 C.i✓ <br />Worlc will commence on or about ► for approximately y: _ 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 />Ift-ndire of Applicant - Title <br />m oMMMftc E=MrAt,uu&&.1171 MSMRPMCWCHMFMPOtAff/PPIJG.t#NOC IWOj <br />Date <br />OFFICE USE ONLY <br />JOB <br />10005— REF # <br />APN <br />CR # <br />EXP. DATE <br />VALID <br />t ze rq TO ---3)1 t do DRIVEWAYS; <br />STREET <br /><r=Trt S/^Atil 4W - <br />v,L,AREA <br />AREA <br />Goy c QUAD / a <br />TYPE <br />A C-Q./AI- N&4 -e- - 7-G r-> <br />FORMS <br />5 M _ <br />NOTES <br />"S FMe,1AZ- Ga,AJWrI DA'' <br />��es. 4-1-7w cN <br />4 1&05T oi; purr �;- 'OaAk' (5 w,-- H I tj -rA6 ctry 6ie- 6004 <br />The undersigned hereby applies for permission to excavate, c nstruct and/or otherwise encroach on County Nigh Right -of -Way on <br />the Al / side of 6 . C-1'�c�E�' d0i' L AI approximately / fe iie,�ST <br />of T{xGe y , by performing the following work description of work): <br />A i c Go 4- -AI' C, <br />-T'� _�- n>- . r� �U.r 1GYt �1� lu}7 �.5 U -7"r. T1Q -4 C.i✓ <br />Worlc will commence on or about ► for approximately y: _ 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 />Ift-ndire of Applicant - Title <br />m oMMMftc E=MrAt,uu&&.1171 MSMRPMCWCHMFMPOtAff/PPIJG.t#NOC IWOj <br />Date <br />