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Y <br /> n f'.' R•' nti <br /> APPLICATION FOR ENCROACHiUtICI ' ERMl�. <br /> S'_ v <br /> PLEASE-PRINT:-,-) _t.; <br /> Date 7 f OFFICE USE ONLY <br /> To: San Joaquin County JOB# X 052-to REF# <br /> Department of Public Works APN CR# <br /> 67 �, cc�F-.,r�`G. 5" p EXP,DATE 2 6S Rio <br /> Q VALID Ip u , TO 2 tS Ifo DRIVEWAYS: <br /> (Applicant Name) k �,, STREET (At,-go ArfE• <br /> AREA S-1bceMKI QUAD � <br /> TYPE ?'Ove...gr Mme, <br /> (Mailing Address) FORMSS/,�� <br /> NOTES <br /> t'^•f P �— �dec.✓�i...a.--s,+,*•-�°O 4 1Y'. tel��3 1� <br /> (City,State,Zip Code) <br /> f 'A. 0 - 3 �( <br /> (Area Code-Telephone Number) <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-Way on <br /> the�a *4 side ofapproximately /,Zs o ' ee ite € -` <br /> °f �` "- `r� by performing the following work escription of work): <br /> Work will commence on or about--:� L I for approximately____days, <br /> l► 7� <br /> I,the undersigned,certify that I am the owner of the respective grope y,or a qualified to represent the owner and agree to do the <br /> work described above cordance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br /> Si ature of Appli int Witte - ' ` f Date <br /> E;WUBSV.1•rXV,ASTER_PS%EgOfi0AC8D.EIITPEFh1TAPPLICATIWIOOC(0110) <br />