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'. <br />APPUCATION FDR-ENCROACHIiJ1ENT PERM!T <br />Date <br />PLEASE PRINT: <br />..3/1 !.26!~OFFICEUSEONLY <br />1'1-20 20,<..' <br />5":.:0 Pil-(*'Jt' <br />To:San Joaquin County <br />Department of Public Wort,s <br />7l!tJf2J11Dr7H~DiJl7ZlCT <br />,(ApplicanIName) <br />11/,sa}('78 <br />(Mailing Address) <br />--11iotzn7D1\J ";C4 ()K&?Y <br />(C1iy"Slale,Zip Code) <br />,20 9-'71 ~-;2.'-1 f..p l) <br />(Area Code.Telephone Number) <br />JOB #/llJt)CJS""REF # <br />APN CR#-------EXP_DATE~I(P <br />,VALID,~~TO giza/lip , <br />STREET fifo€NTbN gP,i P6t::fJl!.e ~, <br />AREA 7lIoRHTDrJ QUAD ~,p'M""Ij),,----__ <br />TYPE \{Q--Wic.-Codrol ~lC..--& <br />FORMS ~S¥=l--'W=J-<J~'_ <br />NOTES <br />DRIVEWAYS: <br />Sketch (Detailed plans may be submitted) <br />$el;i"~)..Ieo LOC.4n6I\J rn4-f?S <br />The undilr~igned hereby applies for permission to excavate.constmct andlor otherwise encroach on County Hi~ght-of-Way on <br />the au..side of 7H012I71lYJ<tPB.-!1t:7e..tfJQ ..oximately,/CJ()(j ~ile_'__ <br />of "",by perfonming the following work (description of work):."Ptu me &201 f9)tt-/3uiLn,5,U <br />Wi Pb'lZSOIUiQ-L WILL lUe:J412.~wlJe'I/g,T~Un,;]R.04fJ:..Ut.;.j"o Il.S 'e12J(J::rlD <br />Work will commence on or about ?days. <br />Jj;/Z()/fa <br />,Date;Signature of Applicant.I <br />I,the undersigned,certify that'am the owner of the respective property,or am qualified 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 />tI.:\C8fiAALSER\.~CESlCl..ERtC/lL\RIB-SV_W/..1/.IASTERPSIBlCRDACH\1ENT PERMITAPPUCAllOlWOG {O~lj~