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_a } ICA'17.c.JN FOR ENCROACHANT NT PERMIT � <br /> PLEASE PIUNT: <br /> OFFICE USE ONLY <br /> Date /0// 7 q-: TOB # -73a 5Z _( REFfi <br /> APN _ - CRV# <br /> To: San Joaquin County highway Department. EXP. DATE !z-I -q S" <br /> v,LLm 10 - 1 W-ei rTO I Z_ 1'If DRIVE,WAYS: <br /> '00'gcif/C G'9S 7-rr> c STREETRACon) rscifuD 2D. <br /> (Applicant Name) AREA ETD c,K-- QUAD S <br /> TYPE TkGiOCH # <br /> SSSS FORINTSSS w U) <br /> (Mailing Address) NOTE M 6,65T 141)ve PeF LT <br /> 2�� rrrv� Vag- FYSI� :e' A"4 <br /> (City, State Zip Code) <br /> - 3 tlG' - 5-3 1!�' ?- <br /> (Area <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans W,be subrait:ec.') <br /> i <br /> i <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> N.ighway Right-of-Way on the t - side of "co� s-4g-'a n& approximately <br /> , by performing t <br /> feet /mile of <br /> following work: (,description of work): /rE-'7 oy <br /> Work will commence on or about d c%o-cEti 21 /-79s, for approximately /o /s days. <br /> I the undersigned certify that!,un the owner of the respective property, or am qualified to represent the owner r <br /> agree to do the work descnbcd above in accordance with the rules, regulations of San Joaquin County and subl <br /> to inspection and approval. <br /> C��--� G 9''�=J psfo 7 -,.9,,S <br /> SIGNATURE OF APPLICANT - TITLE DATE <br /> 5-C-077— N l&,Sa <br />