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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 323/a 0/5 OFF <br /> ICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Pubfic Works REF.# <br /> APN CR# <br /> 381W T31+9k y — 6;AAREFt EXP.DATE <br /> �'1R.c1LP VALID . <br /> (Applicant Mame) STREET TO to-3I-1DRIVEWAYS: <br /> 7 lF 7 P.11 L 14m r /7 p l V E AREA 1;p k ar QUAD _ <br /> (WilTYPEailing Address) FORMS 141j41 <br /> _�'Y .r- 7 NOTES -- <br /> (City, <br /> State,Zip C®de) — — — - <br /> s� X19 4796 <br /> (Area Cade-Telephone Number) <br /> bb(,( <br /> Sketch(Detailed plans may b submitted) <br /> Ifcb <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Hi htiva <br /> the o u side of IjLo SSOM Cov�2r ' 9 y Right- <br /> Of Way on <br /> of— approximately 0 feet/mile <br /> 1 ' ,by performing the following work(description of <br /> 01, Q r <br /> Work will commence on or about S � <br /> _for approximately /01n <br /> f,the undersigned, certify that f am the owner of the respective property, repdays. <br /> work described above in accordance with the rules and regulations of San Joaquin qualified <br /> a dresent subject to inspection the owner ag d e to do the <br /> approval. <br /> .AES1 ,v <br /> ® Applicailt Tlife <br /> _e <br /> FA:ICEFtFRALSERVICESCLE21G4L\PU8-SV.WKV,7ASTF,tPSL-TCROACH;7ENT PffiAfITAPPt1CAi70NDOC(0?713J <br /> ,nn <br /> Rk4 %�r�� f�� <br /> T0.1r,At! S�y <br /> • <br />