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APPLICATION FOR ENCRGACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# /lojo 5� REF# <br /> -Department of Public Works APN CR# <br /> EXP.DATE �? J•' <br /> CV ( VALID 7 , TO 1 yr DRIVEWAYS: <br /> (Ascant Marne) STREET j EINAYS: <br /> Q,tbUS <br /> OUAD <br /> TYPE _ <br /> (Mailing Address) FORMS <br /> ---— Ck � — NOTES — <br /> ( Ky,State,Zip Code.) d0' Al — — - <br /> LICA Gil z d ' ! zaf �', o�✓t 7:�A;y✓I• To /`�c2�o9,nit <br /> (area Code-Telephone Number) <br /> Sketchp(Detailed plans may be submitted) �f <br /> t� IZ01 �ILG G1K-+C1�� Qi'e5kIA5 (n^ <br /> �l ("e- Sj,o_Gt) <br /> Thee undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County HighRight-of Way on <br /> _side of 221 \C1 � A rug approximately way way feet/mile <br /> of by performing the fIlowing wordescri tion of work): <br /> Ca c ,'ems i� Q k. <br /> 14, <br /> �Ld. <br /> � tlj"M�, <br /> Wor!<will commence on or about I ��k _ c,�for approximately u c- " days. <br /> !,the undersigned,certify That i am the olvner of fihe respective property,or am qualifed to represent the owner and agree to do the- <br /> spec ion <br /> hespection and approval. <br /> i <br /> S' nature o`Applicant e Tilde Date <br /> M:ICENTRa.SERMCE=LEPJCALIPUMV.WKV,tASTERPSU3 CROACH;tEtTTPEaliTAPPUCA7nOMD00 (09/13) <br /> I <br />