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�e,r,_Sfr ucl iC 1 <br /> APPLICATION FOR EHCR®ACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dale --___� _ � _ � <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# ` T <br /> APN Z- REF# <br /> � CR#rA GC Ex'.DATE <br /> (AAPlicantName) VALtC' <br /> STREhT L '�Y G 2 I DRIVEWAYS: <br /> d I' O St LAREA 4 TYPE QUAD � <br /> (lVlailing Address) FORMS <br /> NOTES <br /> (City,Stage,Zip Code) <br /> (Area Code�Te[ePhone Number) . <br /> Sketch(Detailed plans may be submitted) <br /> t �- <br /> The undersigned hereby applies for permission to excavate �� P�! `�'411 �� ��� �� ll <br /> the' ,t l.2 e t 1.i ,construct and/or �'�` ���` <br /> UT i� s►de of Q L otherwise encroach on County H►ghway Rg ht-of-`Wa <br /> approximately on <br /> by performing the followin work ee mile <br /> _ g scription of work): <br /> L <br /> Work will commence on or about_( _ _ <br /> 1,the undersigned,certify that I am the owner of the _for approximately. 3 <br /> work described above in accordance with the rules and regulations ons San r a days. <br /> Property,or am qualified to represent the owner and agree to do the- <br /> . aqu►n County and subject to inspection and approval. <br /> Signature � � ••l �•►�� r n�C'I"' <br /> 9 of APPiicant Title �Cs• � � __ � — t��' J,J <br /> Date <br /> 6tICEtMtA�CEy'LERCALIPU9,WWKif <br /> ✓✓+STStP51EkCR0ACHAlEt1TPEAAffTAPPIJCATIONDCC(09713) <br /> 1 <br />