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APPLICATION FOR ENCROACHMENT PERMIT <br />-#~:A~8 <br />OFFICE USE ONLY <br />JOB#13tJ()17 REF # <br />APN CR# <br />EXP,DATE <br />,VAUD DRIVEWAYS: <br />STREET • <br />AREA *TYPE • <br />FORMS <br />NOTES <br />,..- <br />PLEASE PRINT:. <br />'toaa.E I..-AFAVETiE ST <br />(Mailing A~clress) <br />rqa'1,dy (6,,:1.0/(., <br />To:San Joaquin County <br />Department of PublicWorks <br />CALlt':'DR10/A WATEI?.:)IG~(l/jI~E,(Applicant Name) <br />--STOCjL'Tb N (2A QS0l05 <br />(City,State,Zip Code)'~g~4IoLJ-'2J,311 .~(Area Code.ielephone !'lumber) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for pel)11issionto excavate,construct andfor othelwise encroach.on CountyHi R!9ht-Of-W~iL..pn <br />the LI.>urt side of'eN 10 kl Q A¥1 approximately,.fe lie ~rrb. <br />of CO IfilL .'"1J-.,byperformingthefoJlowingwork ciiptionofwor[(): <br />(05 /F:,?J;lq'h O&Aglfta.",,-,~v'",,~LL '7(010 GO1...0 \.I,-X:.3'x '-f I <br />Wor!(will commence on or about 2),~for approximately days. <br />~.1 \\0I,the undersigned,certify thall am the owner of the respective property,or m q alifled to represent the owner andagree to do ihe. <br />work described above in accordancewith the rulesand regulationsof San Joaquin County and subject to inspectionand approval. <br />c:i5twQ ~\bQ ~,Q~b Ckk--,Signature of,Applicanl.Title _~_\<{\l~lp__ <br />~e <br />M.."\CENTRALSERvlCE:ro..E'lICAl\PUB-SV.WK'lMS1ER.PS\ENCROACHMENTPER1I.lrt N>A..Ic:A110N.OOC:((19113)