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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date o Is OFFICE USE ONLY <br /> r <br /> To: San JoaquinGounty JOB# '7 c�CZ� REF# <br /> Department of Public Works APN CR# <br /> n EXP.DATE (� /5= 2z <br /> �!_1 I=C ZA I A V V ,9 TEE � I`LL 1 C,C <br /> VALID _ !''i'0 L4-1,.(--2- �'1L DRIVEWAYS: <br /> (Applicant Narbe) STREET C,Dvo V_C_ <br /> 1(0 o a E . Q9 r-)9 y E�'�- s 1� TYPE I,-QUAD <br /> (Mailing Address) FORMS AC1 u2 <br /> NOTES _ �l�>i <br /> (!�A -' <br /> (CRY,State,Zip Code) <br /> 1, y <br /> (Area Code e Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> r <br /> f <br /> The undersigned hereby applies for ermission to excavate,construct and/or otherwise encroach <br /> .on County Highwa Right of-ofon <br /> thec.o�- side of Orb approximate! y <br /> of 1 car v y . fee mile o ab <br /> by performing the following work( escr ption of work): <br /> 14 L� '�Vcl <br /> wt 0 <br /> Work will commence on or about •5 5• r approximately_ (e " <br /> days. <br /> i,the undersigned,certify that 1 am the owner of the respective grape ,or am qu lii'ied to represent the owner and agree to do the• <br /> work described above in accordance with the rules and regu(aiions of San Joaquin County and subjecf to inspection and approval. <br /> �— <br /> Sig nature or applicant-Title 4Date <br /> FkICENTRALSEFUCEMaMCXXPUBSV.WKVAASTaZPSIENCRCACHkIE14TPEMIITAPPLICAnORD0v(09113) ' <br /> 1 <br />