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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: , Cj <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />G/47-A/040)gs-73v <br />(City, State, Zip Code) <br />78 V8 7 7 <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High -W Right -of -Way on <br />the s/6 side of I�fr10 r +�- approximately feet! ile N�r�'r� <br />of t y2�¢ , by performing the following %vork cription of worm): <br />Work will commence on or about = 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 />/Signature of Applicant - Title <br />UT.EMMLSERNGEWLMULWUUSVWe1W57'cRPSeCRO UgANTPER OK)CAWNDOC IW13I <br />G <br />J d-' -- - <br />-- <br />Date <br />OFFICE USE ONLY <br />JOB # <br />( 10000 <br />REF # <br />APN <br />CRO <br />EXP. RATE <br />3 120 <br />VALID <br />0 3 <br />DRIVEWAYS; <br />STREET <br />NAMm 5T - <br />AREA <br />��2ti QUAD <br />" ` <br />TYPE <br />—mAmtC., <br />FORMS <br />-- <br />NOTES <br />�r G iA <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High -W Right -of -Way on <br />the s/6 side of I�fr10 r +�- approximately feet! ile N�r�'r� <br />of t y2�¢ , by performing the following %vork cription of worm): <br />Work will commence on or about = 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 />/Signature of Applicant - Title <br />UT.EMMLSERNGEWLMULWUUSVWe1W57'cRPSeCRO UgANTPER OK)CAWNDOC IW13I <br />G <br />J d-' -- - <br />-- <br />Date <br />