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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE ;45 V, <br /> VALID '�, / 'ATO DRIVEWAYS: <br /> (Applicant Name) STREET` <br /> AREA. QUAD C C - <br /> TYPE 1,." <br /> (Mailing Address) FORMS — <br /> f NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the lVarA side of <br /> approximately -emote <br /> /mile ( / <br /> of <br /> by performing the <br /> following work (description of work) : Nf�c< G��.4r' cr �'2'X 4' 2` X $-" ��, �Y /✓ <br /> f <br /> ;C'. e 't"'` y`P r" r..'> +�.'"� l�etLv T ty`u$2l {� i-'�'y J'l .�- ���u'c7�• l !, <br /> or, <br /> yr .ccts L G' " "d�`+ �Ft Y a. !"^7 af�zn (}Ci fc G..�Srf � {�e./<►FSE �/�%O{iz�,3��'ri K�S�C,r� �/I <br /> I-t- <br /> 1`�kr p/ac< it ✓,'< !.� a :irk ay'v� j�aD J 4/o <br /> , � '�' :d t,C. ✓mow"u�i aC'S rc cfen Gt <br /> Work will commerce on or about <br /> days. <br /> for approximately <br /> r `.^e Undersigned certiF <br /> g _y that i am the owner of the respective prcperty, -�r am <br /> �..ai_f .-Ld t:: rerrese_it the owner and agree to do the work described abc-.-e in <br /> a;:ccrdance with the rules, regulators of San Joaquin County and -abject t <br /> inspection and approval . <br /> i <br /> i <br /> Signatyrle of Applicant - Title ; - <br /> Zate <br />