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R , <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> Pi-SASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of public Works JOB# j/qhs REF.4 <br /> APN CR# <br /> L i ci f-r, G "t EXP.DATE �� ! <br /> c.,'�r t VALID — d <br /> {App!cant lame) STREET DRIVEWAYS: <br /> AREA L✓/�l �,/ QUAD 6 <br /> (Mailing Addwere s) TYPE �� <br /> FORMS <br /> NOTES <br /> PtyS Zip ip Code) - — —-- <br /> o <br /> (Area Code-telephone Number) f: M 2, ' <br /> Sketch(Detailed plans may be submitted} <br /> The undersigned hereby applies for permission to excavate,co <br /> the side of nstruct andlor otherwise encroach on Go <br /> of -- approximately only Highway Right-of-Way on <br /> -U <br /> feetlmile by perfomung the foilowin work(descdptlon of w lt): <br /> r <br /> 4 Y1 urn CC-n ll�l n <br /> Gni <br /> CA <br /> rYS. <br /> Work will commence on or about <br /> for approximately y} <br /> 1,the undersigned,certify that 1 am ths owner of the respective property, days. <br /> work described above in accordance with the rules and regulations of San Joaquin County and sub'ect to <br /> P pedY�Dram qualified to represent the owner and agree to da the <br /> 1 1 inspection and approval. <br /> N f <br /> 5i -na yie of Appli an -Tit e <br /> i Date <br /> M�'-NfWilsEl�vtc6SfYgaCn�aU2svw,vuisreaas�concgxF7rrp�MR.aCATlott000(a�13� <br />