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(�1•J�7C �,- rw� t-C�i t .,�1e/ kG� c:..� ; ` t a,`JF <br /> Z � aC'S — -IN-) <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Ps- 1 ¢ Uz 7+ 1Date cvt,11 24 2 0 I`I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110005 REF# <br /> Department of Public Works APN pea-iz0--05 (jy,_tj0-ay CR# <br /> f <br /> EXP.DATE Z{-(f <br /> VALID I Z-(-1 4- TO DRIVEWAYS: <br /> (Applicant Name) STREET 1,1 fnn P'd <br /> I AREA I_,Yl(JQn QUAD /V& ' <br /> 3 (.-7 1 H 2(1 TYPE Pr, z cA JeI f'ipc <br /> , <br /> (Mail' g Address) FORMS <br /> tt �, NOTES <br /> (City,State,Zip Code) <br /> 2 <br /> (Area Code•Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> to <br /> 777111 <br /> " <br /> {!> <br /> 12 �yL S�cCv� �ov� 1U �� t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the YA 4 Sit,k side of M t I to o approximately 86' OfeteWile <br /> Of " PVC, ►oG r-r- r n by performing the following work(description of work): <br /> a(Q` YC- arlj <br /> d /2" pv i��t�C ��t r t1�.. G-V-� �Ity-4'� ^��i :. <br /> e <br /> Work will commence on or about c(�-c ! for approximately V 1 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 Date <br /> MICEWRALSERVCE9lXMCPLPUBS/.WKUdASTERPS1Et7CROACHMENTPERIATAPPLICAT*t4-DOC (C9131 <br />