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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />P - ,S IUi <br />Date 41Ait /4-, 20/S' OFFICE USE ONLY <br />To: San Joaquin County - JOB# 110005- REF# <br />Department of Public Works APN CR# <br />EXP.DATE 3 -1 -154120,r4416-1? & w4LL INC VALID 4--Z3-(S TO DRIVEWAYS: <br />Applicant Name) STREET 141ci ch/ Rl <br />1777 0-f/c A(o vp j. itno <br />AREA MAD <br />TYPE f <br />Mailing Address) FORMS <br />W 1 4T avow cq 9fS9W <br />NOTES <br />City,State,Zip/Code) <br />9zs s'7 faz, <br />Area Code-Telephone Number) <br />Sketch(Detailed plans may be submitted) <br />A77 ny -D, <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highu+Right-of-Way onthe ,40elWomM side of W. rr approximately Soo Amile F?r <br />Of J. VeNPH'll Ayr_ by performing the following work(description ofwork): <br />11VJr&61-710A1 6% Df704,11 16n1,f .9*6 d E A( -fyFy/01/,41i dtTi41t .04011114 <br />Work will commence on or about for approximately 3a o days. <br />I,the undersigned,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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />filt'j "i' t/t hr <br />Signature of Applicant-Title Date <br />M:ICENTRALSERVICESICLERICALIPLIB-SVWKIMASTER.PSIENCROACHMENTPERNIITAPPLICATION.DOC (09113)