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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date q 16 OFFICE USE ONLY <br /> To: San Joaquin County JOB # I l00 5' REF # <br /> Department of Public Works ADN CR # <br /> EXP. DATE <br /> VALID TO '�-2C-dK_ DRIVEWAYS: <br /> (Applicant Name) STREET �=Hotz#j or.� 'Q-DAD <br /> AREA I QUAD lJ W <br /> P6 TYPE TRENLhN <br /> (Mailing Address) FORMS <br /> NOTE <br /> 5focA To J � �S?6� <br /> (City, State, Zip Code) <br /> Z�QC �s6-�4�D <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> .�, A TTAC 1-1 ED <br /> � Go�D(Ttoh'�S <br /> I-k-trQ1t M U0 t b 1 1-AN E L kAH� �o THE Co�u85 . <br /> The undersigned hereby applies for permission to .excavate, construct and/or - - - <br /> otherwise-encroach on County Highway Right-of-Way-on-the --Wa side.of <br /> ""Tk4ogmToo 'ROAD approximately Zo C e mile -SGJTt-1 <br /> of 1, WY I2 by -performing the <br /> following work (description of, work) : %A/JTAiL A( rf.✓ W aTEJ2_ S�_E2V P C� <br /> /:�612 ?1J2EF �'s "721JC SSD�. /KJ GLUD/nl_ GO�iVgL 1' I TA a <br /> A1C!s-rWG W A-r Ey?_ M K►J <br /> work will commence on or about _ STE/�d£l2 /J 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 /> inspection and approval. <br /> f�, C��nl �oNS72c CT/ 9 lv� <br /> Signatu a of Applicant Title Date <br /> MUTSR.PSWUSC®L (6/00) ` 1 <br /> i <br /> i <br />