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Date <br />PLEASE PRINT: <br />.2/I/~J('?J J <br />APPLICATION FOIHNCROA.CHMENT PERM!T <br />OFFICEUSEONLY <br />'THo &J TO AJ A lie OI,jrIZJ e.::r <br />.(Applicant Name) <br />Po &>v 78 <br />(Mailing Address) <br />---Y.lL()(UJ Jl!)n .,CA 95Ut~ <br />(City,State,Zip Code)tH I€f <br />0207-7"7t../-;)..LJ(P{J -.6t1Ef-tJ <br />(Area Code.'telephone Number)toAI /Q>Js <br />To:San Joaquin County <br />Department of Public Works J08#1/0005'"REF# <br />APN CR# <br />EXP.DATE~~_ <br />.VALID.~TO Yh<dlCo DRIVEWAYS: <br />STREET "ffi0l<.~"J>,P,"WIlLtVur~kJ> <br />AREA ~6 QUAD 1)1.t.lw • <br />TYPE -r,2A'::£IC.C<>>J7.o!.<::t-~V 'C~• <br />FORMS =S?/""I-'W~w'~_NOTES <br />i j <br />Sketch (Detailed plans may be submitted) <br />S-el:=?q-t7I'TUitEJ.LOC;<7-'T7tJN 1n4PS <br />The un~rsillned hereby applies for pemiission to excavate,construct and/or..c;!herwise encroach on County H~ht-of-Way on <br />the~BL!::£~sideof 77iOIll17DA.i iliJ4UJur(3,l?~oximately../O{Jd ~1_.__ <br />of .by performing the following work (description of wort():.'\•LL /3/..0'-/05" <br />WILl t<Je;:H?f(.I:TB.4{CIIVG.VesTS <br />days. <br />I,the undersigned,certify that I am the owner of the respective property,or am qualifled 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 subjectto inspection and approval. <br />~'/Chc'ef <br />.Signature o/i6ant"Title ~/I/<liJ/~ <br />.Date <br />--.