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A-PPLICATION FOR-ENCROACHMENT PERN GT <br /> FLEASE PRINT: <br /> Date (D A ®� OFFICE USE ONLY <br /> Ta San Joaquin Gounty JOB <br /> Department of Public Works lr'��r 3 I `7 1 ®e6q f1 REF# <br /> APN � CR# <br /> P( XDP.DATEVALI <br /> (Applica[it Name) STREET TO -/ -16- DRIVEWAYS: <br /> AREA QUAD ' <br /> TYPE — <br /> (Aflarling Address) FORMS nrr� <br /> S NOTES <br /> ( 14j,State,zip Code) - -- <br /> [/ P <br /> (Area Fo eTTefephene burn c-r) FEEE. �� <br /> Sketch(Detailed plans may be submitted) <br /> S, len% Ole ' �P <br /> & � <br /> ins'YG�� ern-#ra��Br -to <br /> New Pole, 18,01OF311 ► <br /> Du�'1' Girt <br /> The uu�ndersigned}hereby applies for permission to excavate,construct andlor otherwise encroach on Count High" t;i <br /> !he .N sr�Py side of Y 9 Y ght-o1 Way on <br /> —=�-�1 �c 'r/ approximately 3 <br /> of �r�D S j� v Y . feet/mile _ <br /> by performing the following work(description of work): <br /> .i. ' <br /> 5 e ► <br /> Worlc v�(ill commence on or about_ I l-2�I S • <br /> for approximately /.2 days. <br /> I,the undersigned, cedify 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 regu[aiions of San Joaquin County and subjecf to inspection and approval. <br /> �+ 1 D~.Z2 2GI5� <br /> Signature of Applicant Tale <br /> Dale <br /> FAKE i 'SERI7CEMCLEiICALIRJMV_VJKV.IASTE'ZpSla'CROACH;fE1,7pERhifFAPpVCATIDkDOC(Oo(13) <br />