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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date �z J /S '/'(r <br />To: San Joaquin County <br />Department of Public Works <br />r <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />il�Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />/`daJS REF # <br />CR # <br />�� 1 <br />IA I T6 46LtDRIVEWAYS: <br />ajq4jP&tA 4z)o <br />careMN/ QUAD <br />�2/tL�r�✓�tr/9PP.2oflc� R6siklPla <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwayy Right -of -Way on <br />theN�.�A � �o�� side of ���oos� /�: approximately Zs6 f�est7mile <br />of U„ e;c by performing the following work (description of work): <br />i <br />Work will commence on or after <br />for approximately <br />i <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 <br />licant -Title <br />Y:IPORMS & TEMPLATESIENCRCACHMENT PERMR APPLICATION.doc (08108) <br />Date <br />