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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: �{� <br /> Date -\ Miry RLA .aWO OFFICE USE ONLY <br /> To: San Joaquin County JOB # //C'OJ` REF # e�V /0//10 <br /> Department of Public Works APNCRV # <br /> \ n EXP. DATE 2 O <br /> \ <br /> 1�ILL\R Mme,, l C�U�IC TIC��J Ip ' VALIDIz i" TO Z DRIVEWAYS <br /> (Applicant Name) STREET_ <br /> ` AREA /Zf C-Y QUAD 51AI <br /> 10 5 1 ST JIJLJ TYPE � -4/,= , /;- * <br /> (Mailing <br /> �Address) FORMS SS%vVl�t/, e9 <br /> -2 <br /> r <br /> UK • `'4 l a ` NOTE <br /> (City, State, Zip Code) <br /> �'ROT[f f.rwlb .Mll be acquired from the follovinF prZof-tv-verktrt/,'Inih.lr ruewntr <br /> (••�\ � or rlSht-ofvye GMnitur.-Cun.t,bWuuunotern p.tlLle K.K. Co.. southern le X.R. Co„ <br /> irrlRntfon Dfarletywth—Cltv of Tree <br /> Y,T3v `1 ^ ^I <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> cJ�E <br /> EX HU31T A — WGST orf J--Agalr: cf—KI `/ HhNJktOt.E �hr1o1.1 M,.v <br /> E?,(4It-5IT 6 - l^/F--T SoK�0114 4uHTY G5T As- F3'I1L:r=) <br /> EXH181"f C - C/A—QL.*.T1WA . of Fkpjlll'T Few <br /> 'FXHISIT GERTIFiCA'rE _ o- rNS99ANCE <br /> Exlaie,T c - 7'2AFrlc--cor4rao.L PLA�nl <br /> EXHI(3IT F' - t_ETFER DF 5NCRDAC-44M6t4T P1-OP05A1 <br /> 41131T G - 0AL1WC) a 4- RANO-10DG A I L5 <br /> EXHIr,2 1-r H - UITee IDEA;IFY(ti--, r'(195V- -nFnc- e-A5LE t,j5E <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> �RyZ1p 1S :RQADS approximately feet/mile <br /> of 1, 'EAR JORQuyX C' lAM-'I , by performing the <br /> following work (description of work) : -TFAE 1 67MLLRTI( I of F 1 2� <br /> U1�'Z 1C. GF't13LEvol-ToX\S�'Iyl Cy S i -t>U <br /> Work will commence on or about - for approximately <br /> �go days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> a4-oo <br /> Signature of Applicant - Title p _5�j Date <br /> O W j✓t . <br /> aoCi-L051D- 1a3q <br /> MASTER.PS\FEESCf0:1L (6/28/00) <br />