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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB ## �r�-• <br /> Department of Public WorksREF # <br /> APN CR. # <br /> EXP. DATE 2•�.�d <br /> •� �•2 <br /> (Applicant Name) VALID 710TO DRIVEWAYS: <br /> STREET OC/ y� <br /> AREA n UAD _ <br /> (Mailing AddresTYPE LLs) FORMS <br /> ft%�Ktc , NOTE <br /> (City, State, zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> l <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way onthe /V , <br /> of C7� tyUn/ aP roximately side of <br /> O feet mile LcJerf <br /> following work (description rof work) : s/r <br /> br "Por? by performing the <br /> Y 6�Cd <br /> 4..Cd,7G� 't'J % ? �.iJr+. , r +fa Il' s`� C.✓dl nn -!i �7,fClxfc1. <br /> ✓'icdo(ac !ypf, `?'frf l / 1".. <br /> /1 ,'� Air" SP.c�s 76 <br /> Work will commence on or about <br /> < days, for approximately <br /> pproximately <br /> I the undersigned certify that I am the cwrer of the respective property, or am <br /> +3uai <br /> f4 re uwrer and agree d to reprase _t h <br /> acs, r to do she work described above in <br /> dance with the rules, regulations of San Joaquin Ccty and subject to <br /> inspection and apprc,ral. un <br /> /. <br /> Signature of pJ <br /> licant - Title <br /> D Rte <br />