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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />Date /1/ - /y - l - <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />sec PA011 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way o <br />thePns� ► ccs � side of �; �esc,l� s approximately !SOS ^ feetlmile .�,�p� <br />of by performing the following work (description of work): so I <br />Work will commence on or about <br />for approximately <br />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�lesc�ibed�af�ov� in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />ure of Applicant -Title <br />E;1PUB-SV.WKIMASTER.PSIENCROACHMENT PERMITAPPLICATION.00C (O1N8) <br />OFFICE USE ONLY <br />JOB # <br />�t„�P 1 l f�C�Q� <br />REF # <br />APN <br />CR # <br />EXP. DATE <br />VALID <br />2- llw2bVO <br />(—lS 2v 17 DRIVEWAYS: <br />STREET <br />AREA <br />Y,,.5 <br />f QUAD <br />j <br />TYPE <br />l <br />FORMS <br />NOTES <br />a <br />L <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way o <br />thePns� ► ccs � side of �; �esc,l� s approximately !SOS ^ feetlmile .�,�p� <br />of by performing the following work (description of work): so I <br />Work will commence on or about <br />for approximately <br />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�lesc�ibed�af�ov� in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />ure of Applicant -Title <br />E;1PUB-SV.WKIMASTER.PSIENCROACHMENT PERMITAPPLICATION.00C (O1N8) <br />