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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> 10: San Joaquin County � /,n <br /> Department of Public W !1orks JOB# l [LLl �-c_ REF# <br /> APN <br /> EXP.DATE <br /> VALID - TO (S DRIVEWAYS: <br /> (Applicant NaMe) STREET S <br /> AREA C Cu I QUAD - <br /> �/ TYPE o <br /> (IUlatltng ddress) FORMS <br /> e NOTES <br /> 'City,Sate,dip ®de) - - - <br /> 742 <br /> (Brea Code o Telephone P4umber) <br /> Sketch(Detailed plans may be submitted) <br /> 0&/z 7o6 C',9// Ta /?Rise 4 /'�G aE jo,cveA (lc-971c641Ly M.' This <br /> �i e�v1,4es �s Ta o <br /> /2c� .O�CAI- <br /> 75-7-4 woAk <br /> y/!av/ls. , i,7,1e ,q vc✓/O�i�Ns �9� a ,���/j�� <br /> The undersigned hereby applies for permission to excavate,construct and(or otherwise encroach on County Hi hwa Right-of-Way <br /> the' SaaTfi side of �s /�a/ tY 9 Y on <br /> of_sds�.�,Ca u-.E3,r//elx /ld C�.rla,cJ aPProximately�/ app ' feet/rae_,4Vjr TZ- . <br /> by performing the following work(description of work): <br /> Work will commence on or about /7An,. i <br /> for approximately <br /> ---.........., , days. <br /> 1,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 /> Sign - of ApplicanIfleDate <br /> M:l-ENiRALSERVICES%CLERICAL'PUBSV.WKV"kSTERPSIETCROACH.7ENTPERAi17APPUCA-nOkD00(E9/13) <br /> 1 <br /> L- <br />