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APPLlCATIOI\!FOR ENCROAC~,MEl\lr PERMiT <br />Date <br />DRIVEWAYS: <br />o <br />• <br />OFFICE USEONLY <br />JOB#7'5t2()S"2-REFit <br />APN CR#EXP.DATE --7---I--l6~- <br />.VALID 1-"2./-16 TO 7-1-f6 <br />STREET Ot I!/~ <br />AREA fi£K f:.ftm QUAD ~E~5__ <br />TYPE ~Uhn1.e ..' <br />FORMS hWVRlq 1q"cb fpW(A (NOTES <br />/l.oaa,E.kAF-A\-j ETIE ST' <br />(Mailing Address) <br />PLEASE PRINT: <br />bblM."'10 ~I d.o II 0 <br />To:San Joaquin County <br />Departmenl of Public Works <br />CALI t-DQ j\)I A vi{'lTD?.../)E~(l~)~E <br />.(Applicant Name) <br />~.sTOC!LTbN01 CfSC)DS <br />(City,State,Zip Code)'~0~Lj Lo '-I-~2)J I .~(Area Code 0 telephone [\lumber) <br />Skelch (Delailed plans may be submitted) <br />The undersigned hereby applies for ~emiission to excavale,cQnstructand!QrQtherwiseencroach.on County Hi .Right-of-Way QQ <br />the W--w+side Qf'c::::.lM..\&<approximately C\feet!He ~()\ttJ,. <br />of i/eycn..p.A.,)'...,by performing the following work (esciiption of work): <br />Work will commence Qnor aboul '.~~pproximateIY days. <br />.~II~ <br />I,the undersigned,certify lhall am the owner Qfthe respective prQperty,or a qua'led 10reprasenllhe owner and agree to do the. <br />work described above in accordance with the rulesand regulations QfSan Joaquin County and subjecl to inspection and approval. <br />--d----~-t~--- <br />M:\C8ffiW.SERVlCESLCl..ERlCAl\PUs-sv.WKIMASlERPSlENCROACHMSfTPERMIT APPl.lCAll0ttOOC:(D9t13)