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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date O 4' -Zoo OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73 0-Q-C' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> 1�C� C - 1•iEvJ '$J 51 CSS '�Es� VALID /�OC D C TO DRIVEWAYS: <br /> (Applicant Name) STREET EkawE A.V�c- <br /> AREA SYccxlcTo_tJ QUAD C�5 <br /> 4 O�O W ES 1 Lp� E TYPE "BUJ- 4(C>l..F' I <br /> (Mailing Address) FORMS 5-54-3,A ,.. <br /> NOTE <br /> Z o4- <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> VJ <br /> SkQch�Det5iled plans may be submitted) <br /> 0c, <br /> LU v To S��cCAA <br /> uja) <br /> 0 <br /> Q <br /> 1�Y1 z--7(e,41 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately 18 feet/ NoR-'C'%At <br /> of I ` ;C7�"�-� , by performing the <br /> following work (description of work) : 11JST�LC. Y-L" VkyFt-- '&S `Si-i�J1 c <br /> -To SE-�..�C 30 5 8 S How c �1v o - 4' x.�1' n -I' P4" 6 t.(- <br /> .,J <br /> Work will commence on or about Oc.'CD��Z- �l�o for approximately <br /> 2 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 /> - /ISSoG.� C�AS !-�i5?. Vnl&i.0- /O —4 -O G <br /> S gnature of Applicant - Title Date <br /> MASTER.PS\FEESCKDL (6/00) <br />