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APPLICATION FOR ENCROACEMM PERMIT <br /> PLEASE PRINT: <br /> Date \_ OFFICE USE ONLY <br /> To: San Joaquin County JOB # ��oa5 REF # <br /> Department of Public Works APN CR # <br /> n n <br /> EXP. DATE <br /> l_ _th�o LL�Q,�, Co VALID. TO i2-/-00 DRIVEWAYS <br /> (Applicant Name) STREET adz IlAr-E <br /> (� ^� AREA -TGr�atJ QUAD 5 <br /> TYPE "1r_EJ�V{ <br /> C (Mailing Addreae) FORMS. t5�+ <br /> 9S :L O� NOTE <br /> (City, State, .Zip Code) <br /> 9 <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) <br /> 3'i y Z 15' 1M�a <br /> t �e�Pl�e <br /> LQ�; <br /> The undersigned hereby applies for permission to .exaavate, construct and../or <br /> otherwise-encroach 9n County highway Right-of-Way..ox-the "� - aide. 'of <br /> approximately l„6 C� eet/mile Sov h <br /> of a j• by" e'rforinirlg the <br /> following work (description of,work) : _l.►IIt p� 1- y S$tilQ♦ Ltn'j`Q�jet t <br /> ay Q 1, Qlil �OLL4Q_ <br /> Work will commence on or about -o kp for approximately <br /> S 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 proval. <br /> Signature of Applicant Title Date <br /> IAST88.RS\"=CSDL (6/00) ` \ <br /> 'I <br /> i . <br /> I <br />