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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB 7'306 7 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> T VALIB�'ZG' TO '/ct' <br /> (Applicant Name) STREET <br /> _J 14 A <br /> ;35,0-' Z A16# R1GL- AREA <br /> QUAD _ <br /> -�, (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> ()ol- ) q?v- Zt 7 Sz <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ot�herwise enc�r, �a�cih on County Highway Right-of-Way on the '�/ <br /> t moi' � tJ l r ' side of <br /> of (,aJ approximately _ fee it �5� <br /> by performing the <br /> following work (description of work) : � Tr /Z' � I �+..�: <br /> au X!S/7�ts 'iii ants _ �L' �9,�• <br /> _ T � � rJ GSC X+ <br /> S <br /> X—7 <br /> Work will commence on or about <br /> j for approximately <br /> days . , <br /> the undersigned certify that _ <br /> =i am the c,�rr:er of the respective prcperty, -�r am <br /> ruaiifiec�-tc represe::t the, Owner and agree to do the work described above' in <br /> acccrda ce 'with tce ru]r, re ulaticns of San an Joaquin County and subject tc <br /> ir.speciAa _ ro a .. <br /> Signature licant - Title <br /> bd.e�1� Date <br /> /T=How.IV..) <br />