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�� �z �ol✓r�A �� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ///Lq,'" I LI/ <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( ? REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z.— / <br /> VALID TO Z .(_2p/5' DRIVEWAYS: <br /> (Applica t Name) STREET -e� <br /> AREAt6gti tc- ,-QUAD <br /> Jr 5 qu ,3 Q!S TYPE \ ( v <br /> (Mailing Address) FORMS �Jq,—ire L � <br /> NOTES <br /> le <br /> CA qqC <br /> (City,State,Zip Code) <br /> � ZSj -7&.3 -'1& 77 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> se,6- A7T, , Gil 61 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High. Right-of-Way on <br /> the EA6T/w6-Si side of 1,0&S77- C1V• approximately q/ 2 eet/ ile 1y©g7*4 <br /> ofL� X12 1�2/�,� 5i <>TOC,KIT af13 , by performing the following work( escription of work): <br /> fab e 6 r.'Iza s4 T-i /qT- 70 L6 TO c/J 449 W C—S!. Lel/. L- <br /> Work will commence on or about /2- - /y for approximately ;z C-0 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 /> ,C141T c� rev%a�T� j/ /3-�iy <br /> ig toe of Applicant-Title Date <br /> MICENTRALSERVICESICLERICALIPU&SV WHIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09(13) <br />