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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ,2 -.3 — /S— OFFICE USE ONLY <br /> To: San Joaquin County JOB# ([� (�5 REF# <br /> Department of Public Works .� APN CR# <br /> /n/C VALID <br /> ID 4 TO 4 DRIVEWAYS: <br /> (Applicant Name) STREET Loma,/y- P <br /> AREA /41004 PICA QUAD <br /> �'S�/la /y/c�CcJA S/ /fid TYPE <br /> (Maillilig Address) FORMS S141 142 <br /> VA e,4 1// Ile [.i9 95�& _ NOTES <br /> (City,State,Zip Code) <br /> 707- t1o93 - /�137 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ouA J,-o,6 �,9e/s T /PA/s e /°G ;E Zalven oN T e S'OV7 s,al <br /> -09 461c/c 71?,e,e /ems 900' Ale /Pad id ewrcvl <br /> —ff e L706 Z1A/15 To /.vsTA// New /,s .I/e.e T.c•�L .EXTciv3/o.v .4773 ,< <br /> h.o fr o F The 7h- .,.r /rc�u�.P�s i�c GcS r o�'� C/,e f.r• c /d ,Ci� <br /> 7"fi r Taw,r,r s o 7'A c AAs e L/i4 w .6 T-4 e exA ve //c e s <br /> 7" 6 S.e7'z o IA-1 7h v /1a,4W ;w, ZAC A,- / Z,4*.,e . Ovx T/lA/f. cc <br /> The undersigned hereby applies for permission to excavate,construct and/cr otherwise encroach on County Highway Right-of-Way on <br /> theSa uTh side of ko,le Til c e /ld approximately �00 ` feet/w+te E.fsT <br /> of ,Dye /1d ,M�r,V�c.0 A,rr z, by performing the following work(description of work): <br /> /✓«d % C4,4vVe !/.O e7AJ Z07AIR rCt ,Zo% %C&Amep / 0�e' <br /> ? t /s Al a ga4,1 Td .�, FT %h c Te Qr ca . <br /> Te?.rL 7,1—ie Td g:&, <br /> a/eTe t,�u.c/< iJ dF dee.00ed . <br /> Work will commence on or about 1v14.feA / J'016— _for approximately G O 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 /> /,- <br /> Sign Af Applicant-Title Date <br /> M:ICENIRALSERVICESICLERICALIPUB-SV.WHVAASTERPSIENCROACHMENTPERM[TAPPLICATION.DOC (09/13) <br />