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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASTs PRINT: <br /> Date (2 1 (te IG <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB #- 774-`� REF # <br /> APN <br /> CR. # <br /> �AS�� I �a'LlF'1� VJti� EXP. <br /> DA)"E Z <br /> VALID _ TO DRIVgWAYS: <br /> (Applicant Name) STREET _��RD►s� <br /> 2 Ba <br /> (Mailing Address)a v C. E i b l- �''`1 1.� Z,l� AREA 72gsy- QUAD _ <br /> TYPE * ----- <br /> C FORMS-- � <br /> _ J�C)C,1�T6"� J -I 0 NOTE <br /> (City, State, Zip Code) <br /> Z39 - l 7 4 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> m <br /> 0 o D <br /> --� cn 2 i <br /> o OM <br /> 1 <br /> C <br /> I <br /> coc rn <br /> 0 Mr C7 tT' <br /> Tz 00 i <br /> O C <br /> -4 <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on Coi.mty Highway Right-of,Way on the to j <br /> A" S -(tom <br /> approximate) side of <br /> of � ��E�l. JF y -- feetLMjj�e �� <br /> following work (descripta.on of work) : 1 1�W �A / by performing the <br /> ��µ•l �(7�F �(�l to ji Z l ` '��k-�i 1�. <br /> .�` Frow. ea�,� .�� ?n.+���iz•..-�� �..ja +Z' F�� Dl - n� Pa.J-. '-ti1T s�. <br /> C__(.�1' � �+3Li � i •e.in�b `7 .-:LSE I/ i <br /> 1 S 'Zc (atm FA.4� x rSTIA c t o G <br /> �i2.T' . <br /> Work will commence on or about <br /> � Z <br /> lo L:�p`j <br /> days. 1 for approximately <br /> I, the undersigned certify that I am the owner of the respective <br /> property <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 /> i <br /> nn <br /> Signature of Applicant - Title 6 <br /> Date I <br /> KUTBR-PS\F86S®L (6/00) - <br />