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APPLICATION :FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />6 <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE <br />ONLY <br />REF # <br />APN <br />CR # <br />EXP. DATE <br />VALID TO <br />STREET <br />DRIVEWAYS. <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTE <br />The undersigned hereby applies for permission to excavate; <br />otherwise encroach on County Highway Right-of�Way on the J <br />:eG <br />c hero4€e'' approximately — ���C) <br />of i�`G� C) St r rA <br />following work (description of work) : E. ,o,�,�r� �. <br />worx will commence on or about �� <br />construct and/or <br />feet/mile <br />by perfonil_iI the <br />CJ l °A i CEJ *A0 r-4e� <br />for approximately <br />I, the undersigned certify that I am the owner of the respective property, or am <br />qualified to represent the owner and agree to do the work described above in <br />accordance with the rules, regulations of San Joaquin County and subject to <br />inspecttion and approval. <br />SignatureYof AppA fcant - Title V Date r <br />MASTHR,PS\p885ClIDL (6/00) <br />