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APPLICATION FOR ENCROACHMENT PERMIT <br />'~:~.:C~.iVEDSf;,(.~I j ;~','\'.•L :i<c.;:)U i'~T Y <br />To: <br />Date <br />DRIVEWAYS: <br />* <br />* <br />"fl'"F~~,.,1 •..•9l,!t,;.;',,/1,':':,:-(""_••i 1 •.••.,"C _I.I •.J <br />"',;..~91,'),'~.?'"<:•.,_I j."'-,fttL--(}JO\~I\"" <br />OFFICE USE ONLY <br />JOB# <br />APN <br />EXP.DATE <br />.VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />/I.ooa E I--..AFf)V E1TE ST <br />(Mailing Address) <br />PLEASE PRINT: <br />F &hJ LAC\4lf J,~dD llo(I. <br />San Joaquin County • <br />Department of Public Works <br />CALI T=<)Qf(ji A WATER-c5E~IL/j)Q..E <br />.(Applicanl Name) <br />~STOCILTbN 01 CfS0lD5 <br />(Cily,Stale,Zip Code) <br />'d.og~if 10 L..j -B;3 J I . <br />~(Area Code.TelephoneNumber) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for ermission to excavate,construct andior othelwise encroachon County Higilway Right-of-Way On <br />tile i0.{<J.f side of'.0'L ';L.'approximately,.-:-('fOOl1mile YVorf!-.. <br />of ....-r''..\.,.,by performing tile following work ilEJs'ciiption of worl(): <br />Won(will commence on or about ..1 I 1..<>fo~pproXi~ateIY 0 days. <br />(51'5 It.I,tile undersigned,certify thall am the owner of the respective property,or am qua liied (0 re.resent tile owner and agree to do tile. <br />work described above in accordance with tile rules and regulations of San Joaquin County and subjectto inspection and approval. <br />M;\CENTRAlSERVlCESlCl.ffiICAl'IPUB-SV,WKl!MS1ERPSIENCROACH.i8IT PERMIT.A?PlJCAl101HlOC (09113J