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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2 1,31 /2-0 IS OFFICE USE ONLY <br /> Sun Joaquin Cou^t f [APIN <br /> OS# X300?� 3 REF# <br /> Cepartment of Public Works <br /> CR# <br /> T # -7- EXP.DATE 3/S- <br /> 1 �U VALID Z-1^ZOl <br /> (Applicant Name) STREET ST-� TO `3^ � DRIVEWAYS: <br /> Z nn 4 w)f <br /> 23/Q C . (� M I L C (a TYPE > QUAD ` <br /> (Mailing Address) FORMS `C Y <br /> TQC�t t-� , CA q SZ j o NOTES <br /> (City,State,Zip Code) <br /> 2oq - q3 It -Lf Ito <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S� bn—�IL-CD -Fb+Q5 <br /> f f T 4W 6S2-'-WS-7 <br /> The undersigned hereby applies for permission to excavate construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of-thcowA-f 99 W V'A6 approximately feet/mile <br /> of 1DSA b --'�OU7N <br /> _S C r by performing the following work(description of work); <br /> Er VV 2 ` 0 — <br /> r-- <br /> J <br /> Work will commence on or abouty( <br /> r for app rnximately _ ,c; nays. <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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Lz <br /> Signature of Applic t- itleDate <br /> �y+M'.ic`Iir^Ai 3EN'r'E9ClEkk'PiiPJ9 SY'N!:Mh3lF.APSE;r..q%,aC�VCUTPEPMi'?PFL!CF*>,:ti CCC Cy+YI <br />