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01/20/2014 05:08 1 HORIZON PAGE 03 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINTL <br /> Date U���� / 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> REF# <br /> Department of Public Works APN CR# <br /> EXR DATE z//- <br /> D �aJV`i�4 flJff&^'t�,//re /0 reAarff AIID /0 1'0 !q DRIVEWAYS; <br /> (Applicant Name) STREET S� <br /> AREA —rte QUAD �S ' <br /> Y� k�� ��' �i►rxf 5 TYPE DN d1d✓ ` <br /> Wiling Address) FORMS <br /> NOTES <br /> GOota k/G�. CA 95766-2 <br /> (City,State,Zip Code) <br /> alp '?.59-2110 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> o � <br /> r * o ' <br /> 4 OVA <br /> 4°'� - �. ��aldtfss'• <br /> e = ` <br /> t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the. e''pr side of 01^A t- approximately 'SV feeumile 's-ury <br /> of C. W 4.oc) ReOP, , by performing the following work(description of work): <br /> Kd' r►+Ao Yo wad NAJ Y. I r^I-A 40'A <br /> _ a4e d AE9de"—*- <br /> 41"'aM46,1 <br /> ..d��,+e'_f�+�.cr� ssrs��►ts- .� � mac. <br /> Work will commence on or about /y for approximately *00 days. <br /> I,the undersigned,certify that I am the owner of the respective properly,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 /> ignature of Applicant-Titl Date <br /> �1.KnfttlA4SnMtSGK7P11C41H�DBV.N7lV.N8TFR�pfGa,�p(ypun.�ENf/fSfdArT MfLIG110H.000 N111J1 <br />