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APPLICATION FOR ENCROACHMENT PERMIT <br />Data 07-31-2 <br />Toy San Joaquin County <br />aepa�rient of Pubic Works <br />LName) <br />'�I�JiF I'»GNS y <br />(City, state, Zip Code) <br />2� <br />z � Z- � 53 <br />(Area Code • Telephone Num") <br />s-rn ri - <br />(Email Address) — <br />JOB • <br />OFFICE USE ONLY <br />730052 REF e <br />APN <br />CRO <br />Eli. DATE <br />VALID <br />STREET <br />81151204 4 DRIVEWAYS: <br />, <br />—M ents Rd. <br />AREA <br />TYPE <br />-CoI DUAD <br />Erdal Work <br />FORMS <br />NOTES <br />SS-N—VW <br />Special <br />Sketch (Detailed plans ay be submitted} <br />u1+s K�j <br />^� 6� 6 <br />AfP <br />The undersigned hereby applies forexcavate co swct and/or otherwise encroach on County Highway Right -0f- ay on <br />the _(� side of L l twr c n fs approximately - _k+6 / /ibmile <br />Of w y I Z o . by performing the following work (description of work): <br />Work will commence on or after for approximatelydays. <br />I, the undersigned, certify that I am th respective property, or am qualified to represent the owner and agree to do ftwork described above in eccoand regulations of San Joaquin County and subject to inspection and approval. <br />'7�"SI-z7 <br />Date <br />