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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />'Dale JO-f\IA.~ds J.20 110 <br />To:San Joaquin CountY <br />Departmenl of PubUcWorks <br />CaLI EDf?'j\)/A WATER..cjfill)I~E.(Applicant Nanie) <br />!{goa E.I--AFAVETf"E ST' <br />(Mailing A~dress) <br />-,sTDC,4...tb N 01 qS.;L05 <br />(City,State,Zip Code) <br />'d-og \Lj tQ Lj -ca-31J_.__ <br />~:J(Area Code.Telephone !'lumber) <br />Skelch (Detailed plans may besubmiited) <br />ir 8'd--71OFFICEUSEONLY <br />JOB#770077 REF# <br />APN CR# <br />EXP,DATE .{,-I-I 6.VAUD 3-1./-1'TO {;-Hr.DRIVEWAYS:-r>STREET AIPlJ1(rlve • <br />AREA }foe 'tc1f}14 'QUAD C.C • <br />TYPE 6eUhnfe.• <br />FORMS S"swW R.2/tNOTES <br />-....-... <br />~d:l.S 1~/0_t-Dalf <br />The und~fsjaned hereby applies fOJll1f~!SiOn 10 ~xcavate,constructandlor otherwise encroach on County Hi .Right-of-Wayonthe-JA,)U)'l-:_sideof ~approximately I fee mile .scull-.of..=K.,;1",.,.,by performing the followingwork (esciiption of work): <br />Won,will commence on or aboul'f9r ap~oximatelY days. <br />Y'IJ("I,the undersigned,certify that I am the owner of the respective property,or am qualified 0 representthe ownerand agreeto do the. <br />work described above in accordancewith the rules and regulationsof SanJoaquin County and subjectto inspectionand approval. <br />_-~q)W ~-O()~QQ.~' <br />~~ure ofApplicant.Title t