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APPLICATION FOR ENCROACHMENT PERMIT -PM-. 3104`�I i q <br /> PLEASE PRINT: AJo}[T- ' (OlI qo/ ,62 <br /> Date �2.ul14- OFFICE USE ONLY <br /> To: San Joaquin County JOB# � � � �" REF# <br /> Department of Public Works APN CR# <br /> / EXP.DATE j U -( -T /�� <br /> dUIN'I� Or><l Z VALID Z2- -_[.TO (c j v ac'(J DRIVEWAYS: <br /> (Applicant Name) STREET Av <br /> ry� AREA QUAD $` ' <br /> 1� IVZ1� �a �We- � 3 TYPE <br /> (Mailing Address) FORMS a/C0 �— <br /> �Nsno CA, q3 no NOTES <br /> (City,State,Zip Code) <br /> (ci25) 32? — <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 on County Highway Right-of-Way on <br /> the S-01 side of S015b4- Caron bs 1 r[. (2 approximately i-1 SS Teet feet/mile <br /> Df 1;f f rc(. by performing the following work(description of work): <br /> Wore CL e r l'orc'w ?61e <br /> Work will commence on or about -1 for approximately 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 ab e in cordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 6Aoll <br /> -11Yof Applicant-Title D to <br /> M:,CENTRALSERVICES\CLERICALWJB SV.WKMASTER.PS\ENCROACHMENT PERMIT APPLICATION DOC (09/17) <br />