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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />Date /-- Z3—d <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />/zrv[r-7 S <br />(Mailing Address) <br />(City, State, Zip Code) <br />9 zs 6z2S— 9,96 2. <br />(Area Code - Telephone Number) <br />(Detailed plans may be <br />S� A�AGN� <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of Way on <br />the l&�r side of q51 F"4W R 66 approximately _ t3 Ile <br />Of ' 4,e ENT£s� ,1'z _ ST�4>0—, by performing the following work (description of work): <br />G c� l Cr_7 a4,01r_fT O L E S - p_ fix v�4Trl(d� <br />r�) T 46 7--L-,4- Ger -- <br />u ao r �L T 9-C- e -e- NS -4r, 3 r rz?cVL> 7 -C -- - <br />Work will commence on or about - 2- for approximately 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 />A417- 4,"00Q?1A i4To <br />A#igna—ture of Applicant - Title <br />kK£MF[�1i3E1MC&9ClkAGAL1fU6++"�H7Nl4SiEliP51ElIGfiQ�CJREiiT PE�.WPIIChiION UOC I�%�iY <br />____ I_0_L3-6___ <br />Date I <br />OFFICE USE ONLY <br />JOB # <br />/RODS REF # <br />APN <br />CR # <br />EXP. DATE <br />7,0 <br />VALID <br />VEWAYS: <br />STREET <br />Y F41''A6r. fes• ' <br />AREA <br />-Srw<,C ,p QUAD -6C- <br />CTYP <br />TYPE <br />FORMS <br />4E 1 ek 1, <br />�..j <br />NOTES <br />a �' <br />S� A�AGN� <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of Way on <br />the l&�r side of q51 F"4W R 66 approximately _ t3 Ile <br />Of ' 4,e ENT£s� ,1'z _ ST�4>0—, by performing the following work (description of work): <br />G c� l Cr_7 a4,01r_fT O L E S - p_ fix v�4Trl(d� <br />r�) T 46 7--L-,4- Ger -- <br />u ao r �L T 9-C- e -e- NS -4r, 3 r rz?cVL> 7 -C -- - <br />Work will commence on or about - 2- for approximately 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 />A417- 4,"00Q?1A i4To <br />A#igna—ture of Applicant - Title <br />kK£MF[�1i3E1MC&9ClkAGAL1fU6++"�H7Nl4SiEliP51ElIGfiQ�CJREiiT PE�.WPIIChiION UOC I�%�iY <br />____ I_0_L3-6___ <br />Date I <br />