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�'� r ... r.-M��rnr� �r'►-NT.uI J� r�� �'iL d=:. <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 3 L9 /do I j <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Nate) <br />(Mailing Addrgss) <br />(City, State, Zip Code) <br />a pl ol-Lt-. t 4g ) <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />� Ge; t i 3D� r`. 0&0 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the Wewc side of H5-.v-t!j CZ_a� 7 approximately S70o' feeflmile <br />of- j ��v� fl.,�'r'�� bgre%-Tl . QyeJ IAC4 1 by performing the following work (description of work): <br />_tas ' we c, wt 5 • - <br />Work will commence on or about / Ll for approximately 40 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 <br />L(tCERIRAL$ERV;CEMM''MIPJ0S1,%'NWASTMPVE?ICROACRte4TVFR4TRPPUCATIMI WC COY13) <br />. /to%')vl c/ <br />Date <br />OFFICE USE ONLY <br />JOB # <br />QW* "73bo52'41REF## <br />APN <br />CR # <br />EXP. DATE <br />VALID <br />STREET <br />��-�j� T (7-<1-2y 1 y DRIVEWAYS: <br />�- <br />AREA <br />QUAD <br />TYPE <br />—v^- <br />&-KR a�r <br />FORMS <br />S/W,(Z2G <br />NOTES <br />Sketch (Detailed plans may be submitted) <br />� Ge; t i 3D� r`. 0&0 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the Wewc side of H5-.v-t!j CZ_a� 7 approximately S70o' feeflmile <br />of- j ��v� fl.,�'r'�� bgre%-Tl . QyeJ IAC4 1 by performing the following work (description of work): <br />_tas ' we c, wt 5 • - <br />Work will commence on or about / Ll for approximately 40 days. <br />I, the undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br />work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />Signature of Applicant - Title <br />L(tCERIRAL$ERV;CEMM''MIPJ0S1,%'NWASTMPVE?ICROACRte4TVFR4TRPPUCATIMI WC COY13) <br />. /to%')vl c/ <br />Date <br />