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APPLICATION FOR ENCROACHMENT PERMIT -VM-. <br /> PLEASE PRINT:4 N ` 10-719701S( <br /> Date 4Q/`- OFFICE USE ONLY <br /> To: San Joaquin County JOB# '„ 3c; Lrs, REF# <br /> Department of Public Works APN VCR# <br /> EXP.DATE r 0 2 <br /> 1 _ y i y <br /> �Gtdt2� ®r�l� VALID -22 2f TO lJ -i _Z4;(,, DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA ,1 •,t,. QUAD <br /> $ c( ?"V �(P. TYPE R>i <br /> (Mailing Address) FORMS <br /> i'�rgsnjo (NI U720 NOTES <br /> (City,State,Zip Code) <br /> 327 - aa9-0 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach onPunty Highway Right-of-Way on <br /> the E-Mi side of I a o l0 Su.t 1;4 rj_approximately 452 T-e o f feet/mile Mor4Il <br /> of V;AA/ Aye by performing the following work (description of work): <br /> `-cnjwa, rJ,&tex-1 or r.,W l-ei <br /> Work will commence on or about D I -I 41E. 15 -1 for approximately days. <br /> I,the undersigned,certify th am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described abo e in a r ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> (- 1U64- <br /> g rof <br /> SiA scant-Title 1 Dates <br /> M9CENTRALSERVICEMCLERICAL\PUBSV.WIOMASTER.PS,ENCROACHMENTPERMITAPPLICATION.DOC (09113) <br />