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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICEUSEONLY <br />To:San Joaquin County <br />Department of Public Works <br />CALI t':'()I2JUi A WATEf?-QEIll))I1E <br />.(Applicant Name) <br />'GOa,E .I---AF-A\jEnE ST' <br />(Mailing Address) <br />-STac-'jCTbN 0q Q5C).05 <br />(City,State,Zip Code) <br />(dfJq~if Lv y -'i531 I <br />'~(Area Code.telephoneNumber) <br />S~etch (Detailed plans may be submitted) <br />JOB#17IJ077 REF# <br />APN CR#EXP.DATE ---._.(p-Z+~/'+~w-... <br />.VALID .a7i#?'TO t>1J1Ir.-DRIVEWAYS: <br />STREETr;4JZ:/Q lIy~;I •* <br />AREA '3d~Io/J QUAD £5.* <br />TYPE 8dI#Ok '.* <br />FORMS {j:;/",o/;.J,,(...g.1-t/L;uA CYI /6 J/.dNOTES~,)../------ <br />. <br />The u.ndersigned hereby applies f~~~cavate,construct andio..r otherwise encro~ch.on County Hig~.Right-of-Way on <br />the f u.e.o~side of .approximately .Y'1'\:~mile'l\iOr+)..,. <br />of .tly)'U","-"(t,..,by performing the following work (description ofworl<): <br />Wori(will commence on or about -fO"JapproximalelY days.&,I Iw .. <br />I,the undersigned,certify that I am the owner of the respective prope oram qual fled to represent the owner and agree to do the. <br />work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />M:\GENTRA1.SERVlCES1ClERICAL\PlJIl-SV.WJ{\.•••lJ\STffiPSIB.'CROACH.\IENTPERMfT APPUCAlION.DOC (09113)