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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7'/7— W5 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 730052 REF# <br /> Department of Public Works APN CR# <br /> ,'�'14 EXP.DATE 1 D—LS - L S <br /> I • C7- VALID TO es DRIVEWAYS: <br /> (Applicant Name) STREETF-inkbohmey- Ad <br /> G AREAL C'6_ QUAD J G <br /> TYPE t <br /> (Matting Address) FORMS —A4ftA_XML r- giairz- <br /> L,/(N <br /> NOTES <br /> 5A (City,State, i Code) <br /> 969 16p3Z <br /> c� <br /> �1 S xG (-Qo Czi C 1 20one umber) <br /> Sketch(Detailed plans.may be submitted) <br /> Pt)L e F orti� <br /> 1F <br /> 3, <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right-of-Way on <br /> the_ S)Oyj 1-i side of �I�.I kE�n } _�,�} approximately 90" fee ile�541� <br /> of ), AL Pj!►1 �2/� �Src77jtV ,by performing the following work( Ascription of work): <br /> �1�1 r'l�t1L yylz7 O Q' /Z6A1 <br /> Work will commence on or about .T0wE 04 TOL Y ZOIC for approximately _ OA-16 days. <br /> 1,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 regulalions of San Joaquin County and subject to inspection and approval. <br /> _ 17 /,5-- <br /> ignature of Applicant-Title Date <br /> E.1PU"V.WKVA4STERPSIBeRoACHA1EIRPERMRAPPLICATI0t1.DOC(M) <br />