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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date %I/1e)/C)9 OFFICE USE ONLY <br /> To: San Joaquin County JOB# //Q� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t2-Z3- <br /> \ -e v 4 i vve VALID a-Z1-0 TO 12-23-a9 DRIVEWAYS: <br /> (Applicant Name) STREET LJW <br /> AREA QUAD t <br /> ! 2 Pe 1 i c-c'>n W� TYPE NIGwHT gi4D &PgagE <br /> (MailingAddress) FORMS -- roko,w IPA s;A Af. <br /> NOTES <br /> So,,n , CA 9 49D I <br /> (City, State,Zip Code <br /> 415- 71(o - 957G cc! <br /> /}IS- 453- ';� 32-- f---x-�• 18 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See. aitnCAaer. TC- ►C C-OV' YD( <br /> ���'-V'�-I �i��'r `i� j vt S t�ru vt C� G2.�"�'i f i G�•'�2 t�.I S o c�'�iG�l,eoC l �, <br /> V\o<.✓1A i✓L: S Gk" J 0 GNU L k:1 v\ CO L-1 v\.� C1 S c AcG��a-n^-c t�.t S u✓ C T CaT� <br /> t 1 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Ng ovyA S$ side of ttcav\,Sev\ FA. O Ve-f-crass irnq approximately �•�S fee it Soc,�-Nn <br /> of Ven S os-} � Rd i h 'rc�, cAt , by performing the following work(description of work): <br /> n <br /> levVporckV-LAy'oo�d �1oc�.�y� o 4av-'evN Rei. over cy'ossiv+A lonid'Ae O\rtf' <br /> -two v\ work tit {-s ctY i v` b r i d ' uc o r c��t'c+nS, e id e <br /> Ced tyT"-(6C- (1e_ e vu ov-cx,r ter i d e S o r <br /> vC%ds a v\Ai v-,►A>,uvrn , U�ar i >T r�w. r.�+nde►r vt *-- <br /> W i-f f,, Ccct i F. Dept. of SQe- ak.At-gale.d lam-*-r Gla-t ed S 2-7 09: <br /> Work will commence on or aboutMom z/zt Ion-k' for approximately o 2 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 /> �ear1-eisinc..�+�c.ie! <br /> �ro'e,c� Mavt e� I tlt9�o9 <br /> Signature of Applicant-Title Date <br /> Y`FORMS 6 TEMPLATES'Et,CROACHW¢NT PERMIT APPUCATION.doc IOa OEC <br />