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APPLICATION FOR ENCROACHMENT T PERMIT <br /> PLEASE PRINT: _ _ .�.t.. p <br /> Date � � +•t� 0��0 <br /> 5 OFFICE USE ONLY <br /> 10: San Joaquin County JOB# 73-0077 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> —, ,q 19 1.E j? `_U I(LE VALID TO _7�—/S DRIVEWAYS: <br /> (Applicant Narhe) STREET <br /> AREA 57-ta <br /> 1 o . 9 Fa L/ E S E ST TYPE QUAD <br /> �(Mailing Address) FORMS S W!1Z ezcj <br /> - ,STO L K-71 ©f\l NOTES _ <br /> (City,State,Zip Code) <br /> 1, Y -131 <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the side of <br /> of approximately feet/mile <br /> �� � / 5 �� ,by p rfo Ing the following work(description of worfc): <br /> Worlt will commence on or about _for approximately da s. <br /> y <br /> 1,the undersigned,certify that I am the owner of the respective proal,or am gua fed 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 /> Signature ofApplicant� <br /> Date <br /> M:10EMTZALSERVICES1CLERICAUPtjMvwKLdkSTERP51ETCROACN9IENTPEFhirTApP(ICAl7ONDOC (09113) <br /> 1 <br />