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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To:San Joaquin County <br />Department of Public Works <br />~Vio1 \NtJ1pbI 1?,l~I'VI{'\6ttltJ <br />(Applicant Name) <br />~v1{V ~V~1W~t\vl <br />(Mailing Address) <br />~/Vl'lj1s l \CA.PIC;112.- <br />(City,State,Zip Code) <br />(yO/(,,)lj~Q .0512 <br />(Area Code.Telephone Number) <br />OFFICE USE ONLY <br />JOB#.~\~OoQ,<:REF # <br />APN ~~~CR# <br />EXP.DATE 3-'5-ZaIt- <br />VALID 51-r TO cr-t?:- <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS:• <br />C-S""k-e-tch-:("'D-et-:a-:ile-Cd-:pl-an-s-m-a-y-:be-s-u-:bm-:i"'-tte-:d-:)-------------".------;-:----------,., <br />The undersigned hereby appiies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the70~t-Mt-side of <!J.tA*",~1toM~_~aP..proximately 5!V ~mile \Nt~tof=\II\t.~\-\u',DVJ f?oh\J;IlS$D~W ,\j/\lW.r;\ik e;'l.1J ,by performing the following work (description of work): <br />(\l(A,~V16 '7W/1'1'~hWj i£!\O e~\"'\"1&J ~(oVWiO\lNiIf\i'V v\J\QII\\W\~<-~\N'-II\AJ_rc,~---_ <br />Work wiii commence on or about for approximately dayI <br />I,the undersign d,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br />work described bove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />\IWJ,--t;~lij(~VIlJtA-M,1\"'I'uJ-'2-11.~It yo <br />Signature of Applicant.Title <br />E:IPUO..5V.WK\IM.nl:ItPSU!NCROACH!.u:NT PERMITAPPLICATlon.ooc IC1108) <br />Date <br />,".