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APPS GCA V M FOR ENCROACHMENT PERA W <br /> PLEASE PUTT. <br /> Date ® <br /> - or-FicE USE ONLY <br /> To: San Joaquin County �Og <br /> Department of Public Works APN �� �'�° REF <br /> CR m <br /> U�6_� 1J '-12 <br /> EXP.DATE ^' -- <br /> VALID _ TO ��• DRIVEWAYS: <br /> QAP�u°cantar�e� STREET <br /> AREA <br /> �� ��� TYPES Pi9rQ <br /> �GJlau�o�g A�T�res � FORMS '_ <br /> MOTES <br /> date,zoio Ceded _ — <br /> (Area C©de a e eEe�vho'ne�Uffl erg – <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw Right-of- <br /> the W on <br /> � side of S cc tr ro I <br /> o f rNla approximately / pesclripil'ticwof_fV <br /> ��®c�_n) 1) , by performing the following work( work): <br /> Work will commence on or about �- <br /> _for approximately <br /> 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 /> r5 <br /> Signawre of Apucant.-Title <br /> Data <br /> h11CL[viRAL£ERVICE�CLERICALNUF`svyV V-/ASTER.PSIQICROACHI/ENTPERA!frAPPLICPl OW.00C (09M) <br />