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17 <br /> A: L, L7lt +�V �i^UAC� Q IN, 247 <br /> APPLICATION FOR, HNCROACHKENT PERMIT <br /> pLLA$E PRINT:_ <br /> Date F L '�' c-)q Orricz U93 ONLY <br /> TO: San Joaquin County #—t .� • # <br /> Department of Public-Works APNCRR # <br /> EXP. DATE s s d <br /> - VAL 1J)'1 TO. DRVMAYS'v .. <br /> (Applicant. Name) STRBST <br /> A <br /> AREA QUAD _&,!L 2 +� <br /> TYPB <br /> (mailing Aoareee) FORMS . W�'.,� <br /> NOTE <br /> (City, State, Zip Code <br /> (Area Coda Telephone Number) <br /> Sketch (Detailed plans may bei�(``subtuitted) <br /> The undersigned hereby applies for permission. to excavate, construct and/or <br /> >otherwiise encroach on County Highway Right-of-stay oil the side of <br /> approximately feet/mile <br /> of by performing the <br /> following work (deesoription of work) :. - Q <br /> Work will commence on or about for approximately <br /> . D <br /> days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to. represent the owner and agree to, do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> gnat of Applicant - Title Date <br /> c Com' <br /> � M1Si'6i.P9\dBEB(�iL (s/ao/Aol � -, . <br />