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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date ;;?/Jg/;ttllh~I <br />To:san Joaquin County <br />Department of Public Works <br />J~e5Ee.oTtf€~1¥t-r/ll/G ~,. <br />(Applicant Nal1le) <br />Lf l.J W.If:r;Jl:.sr. <br />(Mailing AckInlss)--r:;~CA qf>37b <br />(City,Stala,Zip Code) <br />(pc?!)'c,3q-J}'13 <br />(Area Code.Telephone Number) <br />OFFICE USE ONLY <br />JOStI f !MQ 5 REFtI <br />APN .,CRtI <br />EXP.DATE ~'+/6VALID4--7 /6 TO 6 }-U DRIVEWAYS: <br />STREET ~M::;9 l-e ve e • <br />AR~U1Z QUAD Yet foI • <br />TYPE Rae(?• <br />FORMS "tr/44/1/R,?<f <br />NOTES <br />wl' <br />II <br />I <br />I <br />Th.e undersigned hereby applies for permission to excavate,co struct and/or otherwise encroaChQll County Hig~Right-of-Way on <br />~90 side!of IN.'"approximately &0 ~ne /luff.of.:,by perfonning the foUowingwo;k (description of work): <br />4''..,'•#',n I• <br />Workwillcommenceonorabout m4Cfl/i ,q 12016 for approximately days. <br />I,the undersigned,certify that 1am the owner of the respective property,or am quarlfied to represent the owner and agree to do the <br />work described above in ae&rdance with the rules and regulations of san Joaquin County and subject to inspection and approval. <br />~.-"/,P: