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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date )I j 4 \el <br />To: San Joaquin County <br />Department of Public +W``orks <br />CIMCJM�r � I ) US- <br />(Ap icant Name) <br />L t.0 <br />(Mailing Address) <br />(City, State, Zip Code <br />(0 -O N.0- WU 2, <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for Derrnissinn to-y-k—ta construct and/or otherwise encroach on County High Right -of -Way on <br />the `T*'- side of x7'GEn It _ approximately e�lmile <br />of or GDb� G 7Y G� min . LU D) , by performing the following work (descriotion of wrk): <br />- <br />- - Guve/z W,`tN/�G <br />Work will commence on or about f%or approximately _ 0 0 days. <br />I, the undersigned, ce* that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br />Wk described above in accordance with the rules and regulations of San Joaquin County and subject to Inspection and approval. <br />1 <br />'I %' Ir< � .� .a' � 1 l ."JMI <br />- <br />N4CETfIilFlSfliNiESU7..�tlCAISNbSV Vf+�'1N1�51ERHs"ENGtQ1RWEM AE7U1[T1PM1GIfON 90C 1171 <br />v <br />Date <br />OFFICE USE ONLY <br />JOB # <br />�pCr REF # <br />APN <br />CR # <br />EXP, DATE3//S-71,10 <br />VALID <br />j2 -1z119 Td I Zo DRIVEWAYS: <br />STREET <br />Tfl.E+�1r9hJ ' <br />AREA <br />lit QUAD <br />TYPE9iG-�l10E5 <br />' <br />FORMS <br />NOTES <br />GAL C &Ipj 7z>l,�S' <br />The undersigned hereby applies for Derrnissinn to-y-k—ta construct and/or otherwise encroach on County High Right -of -Way on <br />the `T*'- side of x7'GEn It _ approximately e�lmile <br />of or GDb� G 7Y G� min . LU D) , by performing the following work (descriotion of wrk): <br />- <br />- - Guve/z W,`tN/�G <br />Work will commence on or about f%or approximately _ 0 0 days. <br />I, the undersigned, ce* that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br />Wk described above in accordance with the rules and regulations of San Joaquin County and subject to Inspection and approval. <br />1 <br />'I %' Ir< � .� .a' � 1 l ."JMI <br />- <br />N4CETfIilFlSfliNiESU7..�tlCAISNbSV Vf+�'1N1�51ERHs"ENGtQ1RWEM AE7U1[T1PM1GIfON 90C 1171 <br />v <br />Date <br />