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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date Z - 2. q- z U/ V <br />To: San Joaquin County <br />Department of Public Works <br />C, (Ji9 f G l- % <br />6, <br />(Applicant Name) <br />(Mailing Address) <br />-_&4 __v"3d 7 <br />(City, State, Zip ode) <br />Z u T-76 97�� c�. r z7s� <br />(Brea Code e Telephon Number) <br />Sketch (Detailed plans may be submitted) <br />zk, k <br />ZZ/�0 <br />m 12J <br />D<_ 14t903?x4 <br />JOB #' <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />Jl' REF # <br />CR # <br />411 � TO DRIVEWAYS: <br />���%S Rol <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />Lodi QUAD AZF <br />`r' <br />retxh <br />5 <br />F0 P <br />/7T7 <br />51vulderWurtk t�fia %uk2K <br />1 5 "J A <br />5 <br />O <br /><-7 <br />The <br />The undersigned her by applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the _ 1side of QeL41 S iZ j approximately t 27 ' feet/mile <br />°f , by performing the following, work (description of work): <br />Work will commence on or about 3 - 3 - 2 0 ! L( for approximately :30 days. <br />1, 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 describe bove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />0 Signature of Applicant e Title Date <br />M:10ENiRALSERVICESICLERICAUP03SV.WKVAASTER.PSIENCROACHMENT PERMITAPPLICATIORDOC @91p <br />