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PLEASE PRINT: <br />Date <br />tU <br />�( /40^5//1 <br />San Joaquin County <br />Department of Public Works <br />APP CA I M FOR ENCROACHMENT PERMIT <br />"k,t4p <br />it r U01FN <br />(Applicant I\ <br />lame) <br />(Mailing Address) <br />l��t�t .j -A 1503 1 <br />(City, State, Zip Code) <br />bliq� MN <br />(Area Code - Telephone Number) <br />C CieS��fi �n:t?5tat�rl�.��=l',ne <br />Email Address) <br />Sketch (Detailed plans may be submitted) <br />tet Kr1r P, 0, c) <br />JOB #i <br />APN <br />EXP, DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />l 6 6 U s REF # <br />or CR # <br />TO DRIVEWAYS: <br />QUAD <br />11C �;;0% iV1 L& AT � oil 0v"rM` t/vA jWEAG %2 OT <br />(7►t�j711. ��G� IP%L5'1- �l" �%iGit�z'�t �eIIC}� �, 'fQf ��.� i � ,.l <br />A fctc4ec� Kc+t tt/e5 1 r(?�l # %4 Ccot,01 � �ttvi <br />The undersigned hereby applies for�permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the Sc�L}� side of � 1_)��� �? �:1, approximately i�L' f.S-et/mile rnlZS'L <br />of s� c.l� Ge Inc to (% r by performing the following work (description of work): <br />9 f7TWye:ii?its' 1V1i;itAe <br />�5 , .t . dVit >it 6r �� w t J 7 <br />Work will commence on or after i 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 �cordance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br />at r of Applicant -Title Date <br />Y:IFORMS 8 TEMPLATESIEIJCROACHMENT PERMIT APPLICATION.doc (08100) <br />