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APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />t of Public Works <br />(AppOcenf NNN) \\ <br />f�Jr)6L4h !may <br />(Mallinn A M rose)I <br />4p1 <br />1'^ (City, St&W Zip code) <br />-ZA- Z-42 V'o 53 <br />(Area Code - Telephone Nun") <br />(Email Address) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />10/1/2022TO /2023 DRIVEWAYS: <br />rroyo a <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />6toCKton QUAD <br />Aeri�7— <br />SSAMN <br />Special Conditions <br />CC ' <br />' <br />Sketch (Detailed plans may be submitted) <br />9 <br />C� � )�a ✓oar-� p '� <br />The undersigned hereby applies for permission to excavate, constrict and/or otherwise encroach on County Highway Right -of -Way on <br />the r- side of I u j , 7 1,l I approximately —` U _ $*Mile r' <br />of i 1, t 1; r ! rr by performing the following work (description of works <br />( x, r. <br />Work will commence on or after %' for approximately days. <br />I, the undersigned, certify that I am respective property, or am qualified to represent the owner and agree to do the <br />work described above in acro with and regulations of San Joaquin County and subject to inspection and approval. <br />"1 <br />gnature of - Title Date <br />