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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / 1+� / – C� %� OFFICE USE ONLY <br /> To: San Joaquin County JOB# /IdDaSREF# <br /> Department of Public Works APN _ CR# <br /> EXP. DATE ?% <br /> VALID ' d Q '.� 2.2 o f DRIVEWAYS: <br /> (App icant Name) STREET L EA1 ,tea It I <br /> / AREA �Se4;ezuJ QUAD 5 <br /> `� �� TYPE <br /> (Mailing Address) FORMS? AZT <br /> NOTES <br /> (City, State, Zip Code) <br /> on <br /> —'(Area Code-Telephone Number) <br /> .� 41ne� <br /> C (✓' j <br /> Sketch (Detailed plans may be submitted) <br /> hack F'i I( -Mrt rk per, r2-25' S�aY,-o(a404 rVU4e.n S u m - s t` <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise en cro ch on County Highway Right-of.Way on <br /> the ,i��%� 7%L side of J)..Lt r,�� �;� P l¢� approximately , , )�feet/mile_ <br /> Of G AIZ2 Z) / 7' 1?A.,' by performing the following work (description of work); <br /> z� /V /) �2 z ,�T �l� /`�,� ,e AliZV <br /> Work will commence on or about , S c? , - p"DsqgroximatelY fT –days. <br /> . <br /> I, 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 /> ,gnature of Applicant-Title VDate <br /> Y'FORMS d TEMPLATES�EIICROACHMENT PER IAIT APPL)CATION.'cc 102/CEI <br />