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APPLICATION FOR ENCROACHIVIEN I PFRMIT <br />PLEASE PRINT: <br />Date � — 2 - 2.4 f I <br />To; San Joaquin County <br />Department ofPublic Works �} <br />��H1�„5 W Q-�'PJ► K.i.wt4o �4�-��irt (� ��Er"/ <br />(Applicant Name) <br />Address) <br />�5 <br />(City, ate, <br />Zip Code) <br />(Area Code - Telephone Number) <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOS # <br />APN <br />EXP, DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />poo r REF # <br />CR # <br />// g 0 g <br />G✓ -1 SAP YE7TiyVeP �iIAAITNE <br />17acx.?yyiJ QUAD : <br />S c.AL a,4P777[)J <br />DRIVEWAYS: <br />I <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />ile <br />the (UI s/e,/ w _.. <br />side of 1nivj e Ye p 4 MP J approximately featlmSDw <br />Of pct, C&M10 (bac , by performing the following work (description of work): <br />V X11 -; Acte, 4iMmeier` <br />will commence on or after <br />approximately <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 />re of Applicant - Title <br />y:1FOM15 b7EA'AUTES�L•NCFiOACHt1Et1iPEP1,UT MPLIC+,TIOtl.doo(Ofl'OD) <br />Date <br />