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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASEPRINT: <br /> Date9/ 3 1 OFFICE USE ONLY <br /> 7L <br /> To: San Joaquin County JOB # 1100S REF # <br /> Department of Public Works APN CR # <br /> --,� <br /> EXP. DATE <br /> 1C.1 ko h VALID -� TO c1�C•c� DRIVEWAYS: <br /> (Applicant Name) STREET }F.o►sr <br /> AREA LIAIPFAI QUAD YO <br /> -Po $C `J F3 6 TYPE "TRWCH <br /> (Mailing Address) FORMS : � rAIIAI R-zq <br /> NOTE <br /> SToGt-CT�n/ Cad 9S2�°7 <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) <br /> S <br /> CoNb�rtn�5 t'0RovtcE. 0L-are $ CU-r qct ?o Al�OCJ a/O.e-worm TRWFF/G <br /> (TNJo 4~6.$) j�(XL/.v� /f/ON- A/Oitli/,vE, NOtle;$ <br /> The undersigned hereby applies for permission .to -excavate, construct and/or -. <br /> otherwise-encroach on County Highway Right-of-Way-on-the N'� fN... side.of- <br /> ='R0)J C —`7T. approximately 540 ' -r <br /> of I GtJE Si", by "•performing the <br /> following work (description of work) : /445A <br /> work will commence on or about Q for approximately <br /> 7� <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 /> l s C�►�� 12vG'T"16� 61,31 <br /> Signatur of Applicant Title ate <br /> MASTSR.PSyPBBS®L (6/00) <br /> i <br />