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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT* RECEIVED <br /> SAN JOAQUiN vOUNTY <br /> Date o 3 k' 2006 OCT '9)FKAgM:IV ONLY <br /> To: San Joaquin County JOii�E T.4WEIC IQg)(SIEF # <br /> Department of Public Works APN CR # <br /> EXP. DATE ID-I!;--0<o <br /> VALID 10-G-0(6 TO Q)-1S-0(o DRIVEWAYS: <br /> (Applicant Name) STREET Ti1X�lo taJE <br /> AREA S7a ckTGl,l QUAD <br /> TYPE A/OLE <br /> 11 (Mailing Address) a FORMS S5� <br /> S� C IC�G'S►-- �:� t �C 2O V -NOTE <br /> O <br /> (City, State, .Zip Code) <br /> 2a9 - 9 3. tog] <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> ('yXyJI-tha <br /> N � <br /> iy3y c <br /> Txe�a <br /> The undersigned hereby applies for permission to .excavate, .construct and/or <br /> otherwise-encroach on-County'Highway Right-of the Ca side..of - <br /> dJ approximately Soo' feet/mile LL39A <br /> of Qs (r�Q u C by ez€orming the <br /> following work (description of work) : {- 1 �n(�at2` 1- y`` �ew-Q0- Le n bl�Qn�Q1� 1u <br /> &a+c g� n <br /> 7 <br /> Work will commence on or abouti Q- to O (P 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 /> (:ature <br /> a on and a roval. <br /> of Applicaat Title Date <br /> HASlSH•FS\PSSS®L (6/00) <br /> i <br />