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APPLICATION FOR ENCROACHMENT PERMIT <br /> pLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date .! <br /> To: San Joaquin County <br /> JOB # '� 9-�7 REF # <br /> Department of-Public Works APN <br /> ( <br /> EXP. DATE O <br /> 1�jiLAT �; .� �I-�1��00� �I�f�I ELI• VALID 0 u Solo_. DRIV89PAY8: <br /> (Applicant Name) STREET <br /> AREA T,�s�Gsi QUAD SW <br /> III <br /> to M TYPE <br /> 10-7P <br /> (Mailing Address) FORMS ��w.,� <br /> NOTE <br /> ti,�pp�s-�o CAS C)s3 54 <br /> (City, State, .Zip Code) <br /> 2011 - 541 - 514-1 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) En <br /> ra , z <br /> n om <br /> -*, > <br /> Qom•- N C TY <br /> n (mss <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on-the �sOU-[}�•.. - side.:o€. <br /> Qty eO6.(] approximately 715( _ feet/mile EAST <br /> Of GO R V=A L k-o u t owl T2-01610 ,. , by-performing the <br /> following work (description of_work) : Pl,b•G� Z'15� O� 2-4n GoNDUtT A.t'in <br /> Q1�1� 30 Kb0 S UC•6FidX ol^1 GOtz26.1.. f40Lt-OW 1Zp ALOKA& WlT <br /> cotkbukl. <br /> Work will commence on or about for approximately <br /> /� 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 /> ins ection and approval. <br /> 3i ature o A icant '- Title Date. <br /> MXGTSR.$S\FSS®L (6/00) .. . <br />