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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> AC-11W�S� <br /> FAREA <br /> FFICE USE ONLY <br /> To: San Joaquin County _�„ REF <br /> Department of Public Works CR# <br /> Z 1 Ito <br /> - 0 9 r /Gp DRIVEWAYS: <br /> (Appdicaratdas�ie) <br /> a�t AyeU6LIU 1/110 It/ - -r6�a QUAD NS <br /> TYPE 1:06u- tol�S <br /> (I (dUdaalsragAddress) MS <br /> NOTES S <br /> � c q spy <br /> (CstY,State,Zip Code) <br /> /-/b� -3A- / 7 67 <br /> (Area C®de-—Te dep—ho ne Nu m ber) <br /> Sketch (Detailed plans may be submitted) <br /> �f Gmcu-fto�� <br /> d^ The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> -ftA side of Al �n��„i., )4%j.*— 4t... .je"- <br /> of �,,ca�,1� Sf- t �ticU- , r. feet/mile <br /> — W�01 ,by performin the following work(description of work): <br /> Wor!<will commence on or abeut <br /> for approximately (� days. <br /> !, the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree fo do fhe <br /> work described accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Si ppdicarst-Title <br /> Date <br /> t.tICEUTALSERUICESICLERICALIPU&SVIVK{/Ag7I�RPSUIC,ROACFtIEIiTPERP.;ITAPPLICATIOR.DOC(OJ13) <br />