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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 1 <br /> Date 2) - 'a 1 r OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> ��,� L EXP.DATE <br /> "07-10C40 l�t UYl� C t t f i6-n VALID TO - -L5' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> I � AREA TC QUAD �4- <br /> lC1 TYPE <br /> (Mailing Address) FORMS 4j j,V <br /> 2L a If- <br /> n 'n n� 1 NOTES <br /> (� 1 (City,State,Zip Cod`e')I I <br /> ate, - E---4P) -o( coo <br /> (Area Code-Tele p one Number) <br /> Sketch (Detailed plans may be submitted) <br /> T ,n d <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of '5 Q CLt+O C_kQ 6 . approximately feet/mile <br /> of by performing the following work(description of work): <br /> 'K a�OL-+e i►il l I e� �r I r v i c�S <br /> n ' <br /> Nork will commence on or about �CQ (S"7. M o��r 1 for approximately t v , �c, days. <br /> ,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 /> vork described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ' M e t i r �, . /F� <br /> Signature of Applicant-Titld Date <br /> nCW1 S CY1021 V1r UCA1'1S"I�YUG'�`C�YI . prn <br /> CENTRALSERVICESICLERICALIPU8-SV.VJK1A01STERPSIENCROACHMENT PERMIT APPLICATIOMDOC (09113) <br />