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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> �5- 13d3 [ C1Z <br /> Date 7--4OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 Q 6 REF# <br /> Department of Public Works APN CR# <br /> EXP,DATE k�� — _ <br /> 'Co. VALID JZIIZ014 TO 6/1IZn j4 DRIVEWAYS: <br /> (Applicant Name) STREET 11,a ' <br /> AREA QUAD <br /> a oeill e�''i�i�ii &440' -6 TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> �",7 -S°`,?.S.Z <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighRight-of-Way on <br /> the tV..E'S7— side of sf/ 61-91g977R,0. approximately--g zo` %1cription <br /> mile �tr�cyl2Ty <br /> of X. "/,PIJ X ,by performing the following work of work): <br /> JGY !/r`j�• 11rlf/'� :'7T 1'��•-�%/�f�7' :ice!/t jr ^•-' .rt'-'f .I!y../4"t ={. .c'%� �,:,,l <br /> - �. �/fr _ %. /! i � /%�J'i' ✓vim= .�rPI ;i/'i, / <br /> i�i'`l/,f.. r_`'i• `f%'r: �:X7,,..>.•r <br /> ..t'lr,' ��: !/ :moi!�� �i.- /�] •f �.��'%`/�'l�7,��/I/J <br /> Work will commence on or about _ for approximately days. <br /> 1,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 /> 7-14!r Z49 <br /> Signature of Applicant-Title Date <br /> E1PL'Fl$JVINlV.4STEA P.$rFHI'T2Q4(:N4�IJT Pf f:MI I.VPLICA(101:UCti (OIrV4) <br />