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APPUCATION FOR EMCR®ACHMEN T PERMIT <br /> PLEASE PRINT: b <br /> O <br /> Date 6 <br /> a c C7 `J OFFICE USE ONLY <br /> —1 San Joaquin County JOB# 7 3(2 0 7 7 _ REF.# <br /> Department of Public Works APN CR# <br /> n � _ _ EXP.DATE <br /> lq ��( S <br /> VV 1�EP nLfkt)I(LE VALID �l—`j— (S TO _( DRIVEWAYS: <br /> (Applicant Manhe) STREET E <br /> AREA QUAD - <br /> �o 0 E . LA FY 1✓-rl 'E TYPE <br /> (Failing Address) FORMS <br /> NOTES <br /> - � I 0 PV 9.Sa-0 5 <br /> (City,State,Zip Code) <br /> L/ -- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach.on County Highway Right of Way on <br /> the iv + side of " E `' S�. approximately feetlmile �i+ <br /> of — by performing the following work(description of work): <br /> --------------- <br /> r' 4- <br /> C IO <br /> art ) t1 tD-P- Ck'J QO <br /> Via' x .goo ' 1%Jr+ ) e',2_[,d0 T' <br /> Work will commence on or about ' rI s for ap r xim:resent <br /> ely Y O days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qua(ified�to re 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 /> ��-��.�� �i��� - n� CSP o,L(�i� � � � • <br /> Signature of Applicant b Title Dice <br /> FA:ICEMRALSERNCESCLER1CA)Pus-sv.WKv AST,R.PSIETCROACHAIEIJTPmirrAPPLiCAiloaDOC(09/13) <br /> 1 <br />