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JUL-15-2009 06:19 From: To:2094689324 P,2/3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �" � �" �_1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 35! REF# <br /> Department of Public Works APN CR# <br /> 1 // 01EXR DATE -ID4? <br /> VALID ,Zz3 &9 TO DRIVEWAYS: <br /> (Applicant Name) �+ STREET <br /> AREA QUAD �y <br /> TYPE ' <br /> (Halling Address) // FORMS r v�.� 'oe <br /> � „Sr,���v NOTES <br /> (Glty, t(a*Zip Code) <br /> / r033 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permis Ion to ex v e,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of /Yl�/ ►7 <br /> of approximately fasumlle. <br /> by performing the following work description of work <br /> u <br /> .I re <br /> a �C O' O Z ' D C <br /> e•.- <br /> Work will commence on or ab ut _GJ1J for approximately p <br /> days, <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 /> r <br /> ignature of Applicant-Title/ 7~ <br /> Date <br /> av�say.',vNwu,nn.wmw�acwp,nperwn�.�wixwouC fouoq <br />