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Y • <br /> ?�9F P�tppa.Sc nD'kr <br /> ►'�4�Vi S�'U SPeGI Z -6r 10c,Abrs a a.4 Co t7 0.• ern # 3101 3 2.S I• -I <br /> APPLICATION FOR ENCROACHMENT PERMIT '' ' <br /> PLEASE PRINT: <br /> Date 7�� LO t S� OFFICE USE ONLY <br /> 11� <br /> To: San Joaquin County JOB# F'�J 7REF# <br /> Department of Public Works APN CR#� <br /> EXP.DATE - <br /> VALID - / TO DRIVEWAYS: <br /> (Applicant Name) STREETlak i <br /> ��[1�� AREA QUAD <br /> (B 50 S'b"l l wa—Aer TYPE " <br /> 'yC> <br /> (Mailing Address) FORMS VkZ�JU <br /> 5(Of NOTES C.)\") <br /> (City,State,Zip Code <br /> G I (f---7 (o 6- 1 Ct $() _ <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) {� <br /> Plezue See- &ra.Wih�S r .XOC 1�tiS <br /> U <br /> a os.he� U0. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the — side of approximately feet/mile <br /> of S f f- &Tt-w:c &A A je_ %,,,s t ju N$ ,by performing the following work(description of work): <br /> • <br /> �i V LX 11d <br /> a.h <br /> Wo will commence o or about L ^ ' 31 for approximately days. <br /> I,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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> L/a- -711& <br /> Signature of Applicant-Title �nrn� T Date <br /> Eipmsv.1/m%sTE psoiCRoAwviTpmvr AmicA7imLD0c(m) - _ <br />