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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3- q rQt OFFICE USE ONLY o <br /> m r <br /> To: San Joaquin County JOB ## /3d,0-$ RE �^ <br /> Department of Public Works P-PN CR ' 3 _ <br /> EXP_ DATE f _•;r; <br /> P/9L/F/C ro�JS ELL��T. G'D, VALID T 27 TO 'Y C I vEN <br /> Lts19 r <br /> (Applicant Name) STREET Atimcr <br /> AREA 1KR!'4T25CR QUAD <br /> lUd �//ol E. /DS,!51n1Ir E A146. TYPE 'SEAL 6b <br /> (Mailing Address) FORMS <br /> NOTE d Cn <br /> /YI�4rVTG:C�9 �s9 gS.3 3� <br /> (City, State, Zip Code) <br /> (20q) C/yZ <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Pm 3DyB5®/aS <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the L19S T side of <br /> /911ZI2O12r 1..JAY approximately .292 feet/roi ly NDiM4 <br /> of Lgr/dleoP InIW rECi4 by performing the <br /> following work (description of work) : <br /> cxr v�9rE 13 11 n/oLc avEA G919 / 41AI R.v1:1 1 el*RL 9,C,i5' <br /> 13 Y XA1.S i A?r <br /> Work will commence on or about 3 .2 7 O fo for approximately <br /> CA") 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 /> . F. LA e-S r/rr1'4 Tot 3 -Y_104 <br /> of Applicant Data <br /> MASTER.PS\FEES=-ML (6/00) <br />