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APPUCATIGH FOR ENCROACHMENT PERW <br /> P►LI=ASE PRINT.- <br /> Date 1-7 A 1 ,5' <br /> OFFICE USE ONLY <br /> To: San Joaquin Cdunty JOB 0 Z3 00,57? REF# <br /> 'Department of Public Works APN CR# <br /> r EXP.DATE _ 1 5 <br /> 5 VAUD . !? b-? T01-1,5-ib DRIVEWAYS: <br /> (Applicanit Marne) STREET <br /> AREA Z _ QUAD 4 Z <br /> W�- L c ne_ TYPE s kicP <br /> (Malting address) FORMS <br /> NOTES <br /> (City,ate,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sket Detailed plans may be submi e <br /> The undersigned hereby applies for permission to exAav te,construct and/or otherwise encroach on County Highway Right of-Wa on <br /> the side of_ ALA ea ry{ /`( approximately/OD -fey 1 e ae ile S9 <br /> of Le_lamd&N cQ , Tra w ,by performing the foitowing workescription of work): <br /> Work will commence on or about I IL — III/ for approximately l 2 O days. <br /> !,the undersigned,certify 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 regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Appliicant-Tide Date <br /> 6UCENTRALSER4CES%CLMCALMUVWKLVA97EA.PSE4CROACIW,Ef4TPMJTAPPLICATICFUICC(09173) <br />