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�7 0� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> rT RINT <br /> 1 2 <br /> pate _ OFFICE USS ONLY <br /> . <br /> JOB # <br /> To: San Joaquin County 23o5Z 2O REF # <br /> - <br /> Department of Public-Works APR CR7 # <br /> EXP. DA S <br /> VALID i t O DRIVEWAYS: <br /> (Applicant. Name) <br /> STREET 'LtopjLmLlT a foV6 <br /> } AREA QUAD AILA.1-- <br /> TYPE _ - oLr <br /> (Nailing Address) FORMS 5s Lyu� <br /> NOTE <br /> (City, state, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> v c9 -"• <br /> cn - <br /> C <br /> 0 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the -i— side of <br /> �)SJ�►J.�:c, -T)��f �2L-LQ approximately i'i� /mile tf c, <br /> of ('� ��/'r-� , by performing�ming the <br /> following work (description of work) :. G? ,–!�`` =-S --J t 2Lac is T-0) <br /> c- <br /> s; <br /> Work will commence on or about for approximately <br /> Le <br /> *y�o,�.i,l`� d ►'8. C A sL�i 0 — r� ` to(L i:'f l ��� �, l l� t��l �s <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 /> =0f <br /> ral. <br /> t - Title Z �� �l zD` Date <br /> G� C f-4P.,11(_- _ � <br /> WATER.Ds\Iczs®L (6/3000) . <br />