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t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ti�Q,r! -LO 13 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �C�2—&_'REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE -2 <br /> MATT Q(LAQW VALID 3k">k" I fl'0 cS 5^ � DRIVEWAYS: <br /> (Applicant Name) STREET N) ' <br /> R J V�A t p <br /> XI< PLAC)r �.l�b FLOOR <br /> TYPE �Q AREAQU D ' <br /> (Mailing Address) FORMS <br /> CA 9 37 1 -0 NOTES <br /> (City,State,Zip Code) <br /> ssq 347— So67 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> €'r1 <br /> 5E6 1J(LAW/V6 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the W 6$r side of S"r. 3O H� approximately 14o feet/rAile /VQ1"-TU <br /> Of C_Lgn(j 4 td A6V ,by performing the following work(description of work): <br /> I30M1,t1✓b ats ' of 4" ffp PI.Asrle- GAS MArrl. C5) 4')r4' 615.0-NoL_fS <br /> Work will commence on or about 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 descnb bove in acc rd nc the rules an�j regulations of San Joaquin County and b' It to ins ection and approval. / <br /> ,( ou-� - i'ro; !/Ll w waw er- —2�2 o�iy Re s a <br /> .�--- ems 9 sTrrrA-f 0(Lt 1-/0-5- <br /> Signature <br /> Signature of Applicant-Title Date <br /> EIPIIBSVYk.ttABTER.PSE11CROACRM'EAT PERMIT APPLICATIOU DOC(010) <br />