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APPLICATION FOR ENCROACHMENT PERM1T <br /> 2 -7 <br /> Li <br /> PLEASE PRINT: . 3 1 <br /> �F�'i, � <br /> Date � �,t �� � l 3 <br /> `� `� OFFICE USE ONLY <br /> 10: San Joaquin County JOB# , 1 - 1-0 <br /> 3 REF <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> f9 I-ER. I(LE VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA <br /> 1 to 0 R E �. 9 F)9 E l f S-T, TYPE to <br /> = <br /> (Mailing Address) FORMS <br /> NOTES <br /> O-A 9.S <br /> (City,State,Zip Code) <br /> y <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> . 1 <br /> The undersigned hereby applies f .-permission to excavate,construct andlor otherwise encroach County High y Right-oi Way on <br /> the <br /> V"),-+ side of_ !� ,�� approximately id �fee mile EnS—E <br /> of by performing the following work(description of work): <br /> , 0- <br /> Work will commence on or about c1 `f S' fo pproximately C� days. <br /> 1,the undersigned,certify that I am the owner of the respective prope ,or am qua6tied 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 /> C�C. � �. �� � �c1�,� Q <br /> Signature of Applicant e Title r Date <br /> IA:ICEMWdSEWCESlCLE21CALUUH-SV,WKLAASTEPLPSIMCROACHMEFITPEFA1RAPpLICA710N.DOC(09113) <br /> 1 <br />