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+ t <br /> APPLICATION FOR ENCROACHMENT T PERMIT <br /> PLEASE PRINIT: <br /> Dale °�.� C 2- ��,-- <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 337� REF.# <br /> Department of Public Works APN CR# <br /> WJ9 <br /> _ EXP.DATE <br /> I-EP, VALID -71 2i_�it' TO I-2f1 ' DRIVEWAYS: <br /> (Applicant Nary e) STREET <br /> AREA QUAD _ <br /> 1(0 <br /> E . �_ r-19 T-1 TYPE <br /> (Flailing Address) FORMS _`> <br /> NOTES <br /> { c✓c r 't _ r� — r <br /> / <br /> (City,State,Zip Code) <br /> I, y <br /> (Area Cade o Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See, -A +T_�che_rl <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach.on County Highway Right or Way on <br /> tha side of <br /> of approximately feet(mile <br /> by performing the following work(description of work): <br /> 7VA9-1GtlS A dDRE✓sSESS_rF k �Crry� <br /> S M QS_2 e) <br /> Woricwillcommence onorabout 7-cr lb 3y;3--/_ -L <br /> for approximately__ (96 days. <br /> ID/'r A <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 regulations of San Joaquin County and subject to inspection and approval. <br /> 7- <br /> Signature of Applicafit-Title date <br /> hi-1cEMRALsl:fmcEs1cLER1CALTumvwKl68A5TEFtpgE,cR0ALHmEMPEmirrAPPLtcAnOMD0C(ORms) <br /> 1 <br />