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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date (1. f ' /[o ' <br />To; San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />Address) <br />(City, State, Zip <br />(Area Code -Telephone Number) <br />(EmaiVA <br />ddres <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the 3G wy� side of F ,/.1 sh lei L•� approximately feet/mile <br />of by performing the following work (description of work): <br />Work will commence on or after G'c,� / �� d 9 for approximately �v 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />of Applicant - <br />Y:IFCRMS & TEMPLATESIENCROACHMENi PERMIT <br />Date <br />OFFICE USE ONLY <br />JOB# <br />% q0I 03 REF# — g <br />APN <br />0$(,_'490— lq CR# <br />EXP, DATE <br />Iai3111 H <br />VALID <br />1011111 TO 1a/3(l1q DRIVEWAYS: <br />STREET <br />&41W 4aKe j Ckoa%dltr 1vakj <br />AREA <br />$66 ie4o QUAD MO R <br />TYPE <br />FORMS <br />1zloyj W; twl'k4 <br />SSlw w lz M . Tyyw In l ui <br />NOTES <br />r <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the 3G wy� side of F ,/.1 sh lei L•� approximately feet/mile <br />of by performing the following work (description of work): <br />Work will commence on or after G'c,� / �� d 9 for approximately �v 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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />of Applicant - <br />Y:IFCRMS & TEMPLATESIENCROACHMENi PERMIT <br />Date <br />