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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date /0_ <br />0' 2 ` l <br />To; San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />zs vs-- 99� <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 High Right -of -Way on <br />EAST side of 42116& �L 5 _ approximately ' fee ile , <br />of /01 L QX by performing the following work escription of work): <br />TGA' -� " J3Lf 0 Exi SLIT -M .TEI&J91 Svc -s. - No <br />IXC ✓►QT/D+V � �LQC,F, -- <br />Work will commence on or about / 2-- Z-- 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 />,r2 r T Gv or7 e>1,vATOL <br />4—signature of Applicant - Title <br />4%CENT MRM941MCALtPUM.WAtU )fAPSEWR04 **-HTPERIXTAPPl"tiOlIWG M33) <br />o- Z q- / <br />Date <br />OFFICE USE ONLY <br />JOS # <br />//OQfls <br />REF # <br />APN <br />I <br />CR # <br />EXP. DATE <br />74> <br />VALID <br />Z Iq <br />TO -31i5-12o <br />DRIVEWAYS: <br />STREET <br />N EftO kms, <br />Rd <br />" <br />AREA <br />_ �.1 <br />QUAD <br />14E ' <br />TYPE <br />A r.a.1 AL. <br />OOLX- <br />P ' <br />FORMS <br />hJ <br />NOTES <br />The undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County High Right -of -Way on <br />EAST side of 42116& �L 5 _ approximately ' fee ile , <br />of /01 L QX by performing the following work escription of work): <br />TGA' -� " J3Lf 0 Exi SLIT -M .TEI&J91 Svc -s. - No <br />IXC ✓►QT/D+V � �LQC,F, -- <br />Work will commence on or about / 2-- Z-- 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 />,r2 r T Gv or7 e>1,vATOL <br />4—signature of Applicant - Title <br />4%CENT MRM941MCALtPUM.WAtU )fAPSEWR04 **-HTPERIXTAPPl"tiOlIWG M33) <br />o- Z q- / <br />Date <br />