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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date j-2-11L1 /f! OFFICE USE ONLY <br /> To: San Joaquin County JOB# '2 5c C>Sr2 —10 REF# <br /> Department ofPublic Works } / APN CR# <br /> `1 CI1 1`{�)� )��1J 0�J`� 5 EXP.DATE l-/,S�Zr>I y <br /> � <br /> VALID 12`10 Z.a5TO DRIVEWAYS: <br /> (Applicant Name) STREET Awry, <br /> AREA � QUAD lU <br /> jf) 12 I 131?LL 11-6� coj y C'�" W TYPE Q tv. <br /> (Mailing Address) FORMS S1S�W W, �2q <br /> NOTES <br /> (City,State, ip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans`maybe submitted) ; <br /> The undersigned hereby applies fqr permission to excavate construct and/or otherwise encroach o County Highway Right-of-Way on <br /> the t side of H�►t�1/J5 k17 approximately 366' ' feet/mile��3 <br /> of- � C-- by performing the following work(description of work): <br /> /ATt5. _-�4PLOSC k C./p) 1 VC -00 lr'k= 5. C11z <br /> AT- <br /> Work <br /> TWork will commence on or about 1 t 1-si 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 agree to do the <br /> work descr' ed bIve in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> tgna of Ap 'cant-Title Date <br /> E:'PUBSV.WI.11AMFLPS%ENCROACHMENT PERWYAPPMATIONDOO(aNJa) <br />