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*rOIl.CO J-'tc.,<)ST*- <br />APPLICATION FOR ENCROACHMENT PERMIT <br />....I ~I_ <br />S td'J h_tit.j Uif'.j C.C::j:~!'y <br />PLEASE PRINT: <br />Date /-20 -Ito <br />To:San Joaquin County <br />Department of Public Works <br />8£';'1.:><..0I Sib A {;)U IfZJt...C,. <br />(Applicant Name) <br />5310 I3tZl,$1J 67. <br />(Mailing Address) <br />f.-/~IOlas ,C.A Q1/5:S0 <br />(City,State.Zip Code) <br />C;1.-5)350-iCj 20 <br />~(Area Code -Telephone Number) <br />OFFICE USE ONI.Y <br />JOB#/lOO(}S REF# <br />APN CR# <br />EXP.DATE 4-6-/6 <br />VALID "l.-Lt/{,TO 4-/5-(6 DRIVEWAYS: <br />STREET Ch-ens I:::.ee erA . <br />AREA 'dvcHnn QUAD t11w'• <br />TYPE r>ace • <br />FORMS $I;WN p:r <br />NOTES <br />Sketcli (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hi h a Right-of-Way on <br />the SE;'side of C.HE:-lt-O:Lb~[7-b approximately -fee mile Not::TrJ <br />of TfJ':Pc E;J"">/Z.,<0Qc(.To.V ,by performing the following wor~escripti?n of work):Borek>:eva,...,::tOld!pOl-b 'To 3(/37..-CN-c:;i..cjC.'I6'b .bf..• <br />i MS:TAl.,L /-7>"GO~»).urr Fate.Ct<1Iv ,sele.VI<k. <br />Work will commence on or about 2.-l.s -I {o for approximately days. <br />1-z o-Ito <br />Date <br />'(g-ttl1/r ~'(y!lJJf:il;rro£ <br />S'gnature of Applicant -Title <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.