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� r <br /> n <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 01 L OFFICE USE ONLY <br /> To: San Joaquin County JOB# 2,6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE f-7-&J&L�3Qiw+ti `r. Q- 11 i�l VALID .�!-2v TO S.t-ZCJ7 r_. DRIVEWAYS: <br /> (Applicant Name STREET "gs.x <(� <br /> AREA QUAD �S _ <br /> A SM VrG7a✓ TYPE tV 1 k O►^= <br /> (Mailing Address) FORMS SS l !,.) i <br /> 1 NOTES <br /> Vi c'to✓ <br /> C141 91soZ S 3 <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pians may be submitted) <br /> S'a a VA T T-A x.14 & <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the W65-T side of 1= r,it )?M,a n approximately S ?bo ' feet/mile <br /> of H 6 N 12 0 by performing the following work(description of work): <br /> OH U ,- �n . T Ll C WryJ 510e o'� tI<tn✓y <br /> . f2o,A Jt STttt"1��,-.� �`( Drs DCS'S �aw.� ��p1v�6nJT� zo♦ f�teo 5�� . <br /> Work will commence on or about U l oproximately Go 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 described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title CE- Date " <br /> U1 CQRf41SERY6ES.CLSLM+NBSY.NhVU57ERfSBxROFC+,VDITPERViTAPPULAMIDOC PY13) <br />