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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> I• <br /> ) / <br /> Date Z b OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> nepartment of Public Works �,� APN CR # <br /> EXP. DATE 7 / <br /> �E�C- r�T SrTLt1c.TZ'a.i E VALID 2 TO WIZly DRIPE9PAY8: <br /> (Applicant Name) STREET WkkadEYA4. <br /> Z Yr4 L_ n I PIL j AREA A6047wGA QUAD SE <br /> TYPEMl/ 5I9A7S <br /> (Mailing Address) I FORMS <br /> NOTE <br /> (City, State, .Zip Code) <br /> V-2!3/1 bj sus- es-s-0 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plan§ may be submitted) <br /> v <br /> m ti Ln <br /> 0 � A <br /> O� <br /> Vts5A6E 8oigezys s/IAzz 46 7WL- /GGt✓,ti1itiJ D Cr'I�9ti7GE�9BCE ^. <br /> NEs5A6E �3or¢,Q,pS� r" � C r�•; <br /> The undersigned hereby applies for permission to excavate, construct anai'03;�3 c- <br /> otherwise encroach on County Highway Right-of-Way on the 4dt�;of <br /> approximately feet/mile -K <br /> of , 1 1. . , by performing to <br /> following work (description of �(ork) : S � -L1C-T� C-r=.� <br /> .o ZL <br /> r <br /> Z CoPY.ES <br /> Work will commence on or. about Z Z y L for approximately <br /> Zo <br /> days. <br /> I, the undersigned certify that I am the owner of the respectiife 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 /> insp c ion and approval. <br /> 33 ature of Applicant Title Date <br /> NASTSR.PS\FBSSCHDL (6/00) <br />