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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:r �} U <br /> Date 5 ' to (� <br /> OFFICE USE ONLY <br /> —1 San Joaquin County JOB# REF.# <br /> Department of Public Works APN CR# <br /> _ EXP.DATE <br /> T=" ( )2N/ )qj EP. �t X01 QE VALID t-S-lS TO7- DRIVEWAYS: <br /> (Applicant Name) STREET _ <br /> 1—/9 6 Y E� f S� TYPE AREA <br /> QUAD _ <br /> (Mailing Address) FORMS c <br /> NOTES <br /> (CRY,Sfate,Zip Code) <br /> (area bode=Te[eptaone�l�am6er) . <br /> Sketch(Detailed plans may be submitted) <br /> Se e �46�Gil eA <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach County High Righf--of-Way on <br /> the k-ks r' side of H t N k Ley <br /> of Li A,g�}�,��,��,5 approximately� 2�Q fee mile s��y T-14 <br /> by performing the following work esciiption of work). <br /> goyEL.F <br /> 5'F-�u LSF R�f'R-i(Z. �Mi�C',r�1Gtif --413 000 <br /> I Cy'i SIX Lo ' <br /> Work will commence on or about S S 15 <br /> for. pproximately <br /> — days. <br /> 1,the undersigned,certify that I am the owner of the respective propeor a5 IS <br /> m qua ied 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 /> df pPIS cL 5��� 15 <br /> Signature of plicant o Title — <br /> Dafe <br /> M:ICENfRgLSERVICESICL&iICAL1PUDSV.Wh'N,Vi5iF7LPS1E7dCR0ACHME7dTpEAhfITAF'pLtOp170NDOC(0?!73) <br /> 1 <br />