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APP GCATM FOR ENCROACHMENT PERMT <br /> 'LEASE PRIs <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County [AREA <br /> Department of Public Works - REF <br /> cR <br /> E v° __- <br /> (Applicant Mame) 70 �� �' DRIVEWAYS: <br /> s`��MP4' QUAD I <br /> (Mailiq Address) FORMS <br /> (t07ES <br /> { ------ <br /> (City, ate, Zip Code) <br /> �I�1/1/4 -7 6x(V 19 <br /> C®de-Iefeph®ne Mumber) — <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excaW,construct and/or otherwise encroach on County Nighwa Right-of-Way on <br /> the V —side of ➢�{ 3 D y <br /> of --_approximately '� <br /> '5'-re's be � by performing t--- he, work(descriptioneile (,c) <br /> g of work): <br /> Worl(will commence on or about IS- <br /> for approximately 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 /> AP <br /> & --po—ON <br /> Signature© 17— <br /> f Appiicantt-Tide <br /> Gate <br /> I,f:ICEflTRALSERVICESIGLERICALIPU2SV.1VKl`/ASiLR,pSI'�ICROM;N.NEiIi PERI„liApPLIGA7101i�OC (0�/i3) <br />