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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />Department of Public Works <br />€J2.'c.SY'\ITH.(Applicant Name) <br />lfCl?J kEmPTON Ave <br />(Mailing Address) <br />M0 NreR.6(~ty~~p ~~e)1''tSS,~","~5-iSS \(Area Code.Telephone Number) <br />DRIVEWAYS: <br />• <br />Sketch (Detailed plans may be submitted) <br />tz,t/fli:SI9i/?6erv-r'/ZP.•.1)/JV/S RD.-1'6~r/(},e.,ltD.-60iA/C'12.$I'lCLl'9.M'~~,,"D.- <br />..;---/AJoot>SbN ~D -;:T1'lH'19NT""t!z>.-~U!-/6VZ,eD.r.ec/H ~D/e:'/n'.t:/_/75 <br />~S-rATlS "E!oVT"6 88. <br />fLeltoSG'SE't£,4rrIfCJtn'l61Vl.S <br />The undersigned hereby applies for penilission to excavate,Constructand/or otherwise encroach on County Highway Right-of.Way on <br />the BNTlA6 sideof A~4bwA'f approximately C:ZItildes feetlmile _of ,,by performing the following work (description of work):kKt..hJ Tlll/£"PCAyF04,/IljA 'heyell!~U.i flflf4p See Ih-rActteJJ ~€ <br />'"0 €oS ANA It""rr;M AfS <br />Work wm commence on or about5~1"-Ie./9:10AM ••••Il):S'S"A ••••for approximately 'j'S"In.""fei days. <br />I,the undersigned.certifYthat 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 JoaquinCounty and subject to Inspection and approval. <br />~-I>-I"Date