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APPLICATION FOR ENCROACHMENT PERMIT <br />OFFICE USE ONLY <br />JOB#it OOOs REF# <br />APN CR# <br />EXP.DATE f-ts -fr,. <br />-VALID 3-11-16 TO 4-1>-1(:,DRIVEWAYS: <br />STREET •LPI"''''trs )/,,/•AREA To",:y QUAD <br />TYPE I\2re • <br />FORMS t;SWW'B"l.!1NOTES - <br />--- <br />PLEASE PRINT: <br />Date 2-).L/-;loI0 <br />To:San Joaquin County <br />Department of Public Works <br />h;;d {dn;;ruc!rcYY7 <br />(Applicant Name) <br />loZfJ marc/III jqr1~ <br />(Mailing Address) <br />-------Cae-ScrC.,.,9fi."f(}7 :__--_- <br />,(City,State,Zip Code) <br />YfJ,)-S26-fJ1G6 &/1 td9-t,$-Z7'l9 <br />(Area Code:ielepholle Number) <br />Sketch (Detailed plans may be submitted) <br />The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the to•..•-\-t;Jt~-sideof -LA VV!1!1<?,.-gcA -approximately So'feetfmile_-__ <br />of ~'_7__----,_.,,by performing the following work (description of work): <br />D\~2.i3alLE-sl<lts j5"'-f,ofV1 Aloe Eal')e of f"\lcm"'l~{3c(lE _1A"c,(&,r <br />L<!J!V!l'l1e(5 lZd f,o,'"+h_~E,,-<t 5de to the ~d Siet<!.,0\n,<A 3'l"1c.£..:-{het.l'pbon«S'HvI-U wi!tl=fcc AH,l",,,,,,,,,,er~GJ...i.,z."j !dlM J'rQ,YI-t -\.tV <br />Work will commence on or about _z_._z._'1_._z._o~t_(.,for approximately \days. <br />I,the undersigned,certify that I am the owner of the respective property,or am qualified to representthe owner and agree to do ihe- <br />work described ve in accordance with the -rules and regulations of San Joaquin County and subject to inspection and approval. <br />Z-z<-/-zdI0 <br />Date