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;? <br /> -0 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: f �J <br /> Date r r 1/4— 2- ! <br /> OFFICE USE ONLY i <br /> s <br /> To: San Joaquin County JOBREF r i <br /> Department of Pubilc Works APN -� CR <br /> EX?.DATE S (S -/ G <br /> VALID17-/ TO /-15- DRfVE+�JAYS: <br /> (A iicant)Name) STREET �;' f pl-)radl � <br /> AREA vfQUAD ' <br /> TYPE <br /> I <br /> (Mailing Address) FORMS W& ze <br /> MOTES <br /> (City,State,Zip Code) <br /> 92S 32.Eo � <br /> (Asea Code-Telephone Number) <br /> l Skatc;i(Detailed plans may be submitted) <br /> 1+604 r,� Doy-&ioI <br /> l <br /> i <br /> The and signed hereby aprli s for permission fo excavate,construct andior otherwise encroach on Count Highway Rig t-of-41lay on <br /> Ghat side r t t=i aoproximately���— fee+`mile <br /> of Z r"cLt�4 M C>r U�sf(5y performing he foilo�wing work(description of work): <br /> IL-171 <br /> FVLE- <br /> Work will commence on or about for approximately, days: <br /> I,the undersigne ce tify that I An thepiner of the respective property,cram qualified to represent the owner and agree to do tre <br /> work described a v actor a therules and regulations of San Joaquin County and subject to inspection and approval. <br /> 6— wig <br /> Signat u/ of ppfi ant-Tit(e- Date <br /> I <br /> E•�:ssv�x,�n��s�a�v„ ;�:rn=ai�s�xa�;wnzi <br /> f <br /> g� <br /> 4 <br /> i <br />