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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 10 -22' <br />To: San Joaquin County <br />Department of Public Works <br />L, uoew Pt. L �2 tor 6% <br />(Appp, licant Name) <br />D. &0v '�- <br />(Mailing Address) <br />�INOc�u <br />(City, <br />Zip Code) <br />(Area Code - Telephone Number) <br />v�la.�; Ir-� �vv.v <br />ai 1 .�0., <br />ress) <br />Sketch (Detailed plans may be submitted) <br />r� <br />I <br />J PV <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County Highway Right -of -Way on <br />the Qt;t►� side of �rq�c''� �� ��T S � approximately feet/mile <br />of by performing the following work (description of work): <br />��TL'vc�-N 4�N1�� Sfi. -� Wl��-�. STy►-� �cc't�yJ/5�,12 % , 'ZO1 `1 Fnc wi <br />Y V' <br />40i*irw Li "Dr—tom Cr, v►nw vj.; i r \1 <br />Work will commence on or after <br />. <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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />rN <br />of Applicant -Title <br />PERMIT APPLI <br />Y:IFOR`i/S 3 TEMPLATESIEMCROACHNENT <br />CATION.dao (08108) <br />Date <br />OFFICE USE ONLY <br />)B# <br />�j()Q')� REF # <br />APN <br />CR # <br />EXP. DATE <br />12-17119 <br />VALID <br />2, 9 TO 2.DRIVEWAYS: <br />S <br />FjP_0"r ST. <br />ATREET <br />REA <br />QUAD IJ6 <br />TYPE <br />_/-lAnDEA/ <br />'T3MP. /EcA D CG0SUaj5 <br />FORMS <br />NOTES <br />�/VD6�t/ fiQG�DAYCb'LESQA7�D <br />GHrto ! Ce'reE C/V &/ <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County Highway Right -of -Way on <br />the Qt;t►� side of �rq�c''� �� ��T S � approximately feet/mile <br />of by performing the following work (description of work): <br />��TL'vc�-N 4�N1�� Sfi. -� Wl��-�. STy►-� �cc't�yJ/5�,12 % , 'ZO1 `1 Fnc wi <br />Y V' <br />40i*irw Li "Dr—tom Cr, v►nw vj.; i r \1 <br />Work will commence on or after <br />. <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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />rN <br />of Applicant -Title <br />PERMIT APPLI <br />Y:IFOR`i/S 3 TEMPLATESIEMCROACHNENT <br />CATION.dao (08108) <br />Date <br />