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*-F'OQ.COH~~T* <br />APPLICATION FOR ENCROACHMENT PERMIT <br />;••.•l ';,!. <br />S/;,f!JO:\~LPN ~:CUr'~r y' <br />PLEASE PRINT: <br />Date /-Z.1-1 W <br />L.Ivf:frUt-1 0 fl.h,c.A 0t{550 <br />(City,State,Zip Code)qz..?i 7 f.s -?'3 8l-.V(a Code -Telephone Number) <br />2016 Jill':28 Pi'I 2:09 <br />~~,.-~.).(.,:.1,:)1:r-\lj';l-);:''':' <br />OFFICE USE aNI.Y <br />JOB#"lXJO~REF#• <br />APN CR# <br />EXP.DATE f-/5-16 <br />VALID "2.-l.b-~TO 4-($-1(;DRIVEWAYS: <br />STREET .Be1v:/ere AI/ <br />AREA ~VJ QUAD (L . <br />TYPE .ore <br />FORMS S)WWgzy <br />NOTES <br />.8 .e:"SI<l 6T,-,-,__ <br />(Mailing Address) <br />To:San Joaquin County <br />Department of Public Works <br />SCfi0CO/AltJrONiO fJrJ))UJOr(Applicant Name) <br />53(/0 <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permjssion to excavate,construct and/or otherwise encroach on County Hi~ight-of-Way on <br />the EAS[side of BELLlf:;Df;ill;A Vb approximately -I 7 I fee ile SOlAr H <br />of E.cue.L../i)A 16:,STaUe)6,,0 ,by performing the following work (description of work): <br />60a!ij-££'01-:1 (,'W;T ,,v '"e,ATi.l v ,'<lldLT Tc::>bAr L 0 E 6.'2Y S <br />AI (,A)lU'."Qt-')Iq'(.(oW EELVlCPEs€:G AVfS)I".I.<,TIJLL 1_1.r~ <br />COIu})l4/T Eon cATv s.8evlcJ<" <br />Work will commence on or about 2 -2..'9-'l(p for approximately LIS days. <br />/_.28-'(p <br />Date <br />1t-e.}/JfT <br />Sig ature of Applicant -Title <br />t,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.