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• APPLI ON FOR ENCROAC'ffi PEFUNUT <br />PLtISE PRINT: <br />t _� Z 3 OFFICE us ONLY <br />Date Of2G� Z JOE REFY <br />IAPN _ - CRV# <br />To: San Joaquin County Highway Department. <br />('applicant ?'game) Y <br />a - <br />(Mailing Address) <br />(City, tate Zip Code) <br />(Area Code --Telephone Nuffiber ) <br />- Tvr�ffl <br />VALIDZ <br />i SjPO DRIVEWAYS: <br />STREET / Q <br />AREASp-GY,L'j'Dh/ QUAD A/r✓ " <br />TYPE 72r-.vIPc'Ca5yeE- <br />FORMS <br />NOTE <br />Sketch (Detailed plans may be submitted) <br />i- <br />co <br />crs <br />;r <br />T <br />c <br />a" _ <br />Fn <br />Q <br />-o <br />x <br />n <br />-�- <br />�,t <br />c-, m <br />N <br />The undersigned hereby applies for permission to excavate, construct_ d I otnerwlse encroaca on t,ouly- <br />N;a way Right -of --Way on the side of 1G approximately <br />fleet /mile of performing the <br />fo owing work: (de ' tion of work j:35� <br />J V • - <br />Work will commence on or about 1 for approximately days. <br />I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br />agree to do the work described above in accordance with the rules, regulations of San Joaquin County and subject <br />to inspection and approval. <br />%%i _ t <br />'X Pc- OF APPLICANT - =E DATE <br />