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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />Date 16 -- Z13— 13 <br />Ta: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />Seic- /r/T/,4ci4t_:b <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highw Right -of -Way on <br />the SK side ofLu. - w_d approximately 2 Z&'7 _Cfeeonilei_ <br />of b,Qvs :M> by performing the fallowing work (description of work): <br />Work will commence on or abouf , I _ _ — - r 4for approximately .o _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 />Signature of Applicant - Title Oate <br />1A0NiNA1%WCESi DWALVVWI'aWA81'EIIPS+EHCRa1GwEH1 PC WTAP�Wg DOC (0131 <br />OFFICE USE ONLY <br />J0B # <br />` REF # <br />APN <br />_Z1,9005 <br />CR # <br />EXP. DATE <br />3 ISr 20 <br />VALID <br />Q q _ T -6115-11-6 DRIVEWAYS: <br />STREET <br />r E 12A . <br />AREA <br />lint _ QUAD NO ' <br />TYPEi�Aj6H <br />FORMS,,/tl, <br />,..�EP�A� <br />NOTES <br />rn <br />Seic- /r/T/,4ci4t_:b <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highw Right -of -Way on <br />the SK side ofLu. - w_d approximately 2 Z&'7 _Cfeeonilei_ <br />of b,Qvs :M> by performing the fallowing work (description of work): <br />Work will commence on or abouf , I _ _ — - r 4for approximately .o _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 />Signature of Applicant - Title Oate <br />1A0NiNA1%WCESi DWALVVWI'aWA81'EIIPS+EHCRa1GwEH1 PC WTAP�Wg DOC (0131 <br />