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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: II • 18 •'� <br /> Date ` ` — OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7960 REF# <br /> A <br /> -�^Department of Public Works APN CR#` -'T W=A— ALATE /2t /3 <br /> D <br /> 1�Sl3 TO /2 / l3 DRIVEWAYS: <br /> (Applicant Name) STREET I1�/ <br /> t� .tel (� M <br /> ►" 1 �J�Y' AREA QUAD 416 <br /> TYPE CZ f0b10 <br /> (MailingAddrdss) FORMS <br /> NOTES <br /> Cn <br /> Z-> (City, e,Zip Code) <br /> (Area Code-Telephone Number) <br /> 6 Sketch(Detailed plans may be submitted <br /> UD <br /> EE , <br /> m \ <br /> s <br /> i�11_L r-AT 'ACHE p <br /> C <Y <br /> t_ J �oro' + _ _.. .�, \ <br /> L J <br /> �' )( -%* PIT 3'��' PIT' <br /> The undersigned hereby applies for permission to excav te,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of III COLLr('-r approximately feet/mile <br /> of ,by performing the following work(descr' tion of work): <br /> 2 - �' I r� tt �#' e <br /> a ra �d �.r ►c. ^� .r ca... 11 <br /> r --t h <br /> be---n <br /> Work will commence on or about ha_=�5 13 for approximately days. <br /> 1,the undersigned,certify that 1 am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> Cd <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Cd <br /> a <br /> Signatuille of Ap@cant-Title Date <br /> A G t t n ca+-a-r'o <br /> r <br /> OD M10E11fRAL5$NILE ICAL1'U4S YYK STERPSIEAGRO PERYRAPPl1CATION.DOC(09/13) <br /> Ln <br /> 0 <br /> N <br />