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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date X41-- Z) OFFICE USE ONLY <br /> To: San Joaquin County JOB # :7 305Z ?O REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET Ro $ #4V--,GN Ep. <br /> �✓ r AREA -r)UCV QUAD 5o <br /> `7 d-d-Li J IA 1V TYPE $F.-A. Nom <br /> (Mai ing Address) - ,w�L FORMS .; > -29 <br /> A� NOTE <br /> (City, State, Zip Code) <br /> }?Z/' V14 !7 <br /> (Area Code - Telephone Number) 9 <br /> Sketch (Detailed plans may be submitted) <br /> AJ6"1- <br /> oe�✓,4:3e �� lZll fl�= 4r'9rri 5r1P.l '.t 77-4-heLe ]( r P 111 I <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 feet/mile <br /> of by performing the <br /> following work (description of work) : � 1.4'Li � r sz �rc.��res <br /> N- <br /> 90-J46 lzliL,.1134�-.= <br /> Work will commence on or about 13e-e- L zoel' 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 /> smdom oiiq.nd 40 •id30 <br /> < s--// � h �� ,ru.e.w L Z AON 9001 // 4/ 4� <br /> Signa ire of p icant - Titl Date <br /> l.hiflilJ Mill V I + <br /> MASTER.PS\FEESCHDL (6/00) Q 3 A l 3 0 3 8 <br />