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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datef o—28—6 OFFICE lJSE ONLY <br /> To: San Joaquin County JOB# 11 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE DRIVEWAYS: <br /> VALID 4 TO // ta D <br /> (Applicant Name) STREET 1� /D• <br /> AREA OVWQUAD <br /> TYPE <br /> (Mailing Address) FORMS. <br /> NOTES <br /> (City,State,Zip Code) <br /> 2-q _ -x-22 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highz <br /> Right-of-Way on <br /> the side of ,tAtPrn� + approximately l ( mile <br /> of by performing the following work(description of work): <br /> C -T L-C;cA -ri0715 WETP-s* 5T La=Ls z -r«a 2 tav -rn DCS/, <br /> 0 tilt 4 PD5 f0' 'D—� t alt. 11.l� 1'i�c�3L t 7- Co"-5 To 5 <br /> �pyfDwA {�tC'+ ►47 'F i�Fc t <br /> t.�i- Kcrr"ietP Ta ac- cis Z <br /> aL T� wtaJxrr�1� �,(�+yrtc t>�t+-� —' 15�w r Fa{ .s p eve. Lo cn►-rtts .l9 <br /> Work will commence on or about —4 for approximately ©13E 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 /> pdesccribedve in cc dance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br /> A plic t Title'70 Z-218 - Bate <br /> TPER APRUcAnoN,d-10 ) <br />