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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 11 A /zoo q OFFICE USE ONLY <br /> To: San Joaquin County JOB# //00 REF# <br /> Department of Public Works ApH ---- — <br /> CR# <br /> G <br /> EXP.DATE (P.•NZ -},11t f`lj� ?I}M �^,. fir_ .1 K1� VAUD //./(o•O TO 12•/d _ DRIVEWAYS: <br /> (APpearrt blame) QSTREET We �erX.lr� 2�? <br /> AREA -7 �_ QUAD <br /> 4 e 4 t C TYPE <br /> ,�v = <br /> (Ma►Bng Address} FORMS — <br /> NOTES <br /> (City,State,Zip Code) <br /> i <br /> Area Code-Te#ephone <br /> i <br /> Sketch(Detailed pians may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise enc <br /> the side of roach on County Highway Right-of-Way on <br /> Of approximately feet/mile <br /> by performing the folbwin g work(description of work): <br /> Work will commence on or about ,r. 16 -too q <br /> for approximately days. <br /> 1,the undersigned,certify that t am the owner of the res '— <br /> Pective 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 /> nure of Applicant.Title <br /> Date <br /> to <br /> --" <br /> E:PUBbV.WK"SfEFtPSE l:RC)ACF NrPERUTAPP=TX3a.onc MUM <br />