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APPLICATION FOR ENCROACHMENT l"ERMiT <br />OFFICE USE ONLY <br />DRIVEWAYS: <br />Z~V07?REF # <br />CR#--~~~-9-/5-/(, <br />9-4-/b TO 8-1>-/69+hS'+nrHol/1 QUAD >'.5Iftor»f<-L9 <br />JOB# <br />APN <br />EXP.DATE <br />,VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />PLEASE PRINT: <br />d(aMlu q :1DJ6 <br />To:San Joaquin County <br />Departml;lntof PublicWorks <br />CBU T=-()t<tD/A viFlTEf?-t>E~(lD)~E <br />,(Applican!Name) <br />Il.ooa.E,J.-..AF-A'4ElT'E ST' <br />(MailingMdress) <br />...sTOC-KTO N 01 qSCi-DS <br />(Cily,Sta!e,Zip Code) <br />(d-og~Lf [0'-1 -B;2>}I . <br />~(Area Code"Telephone[IIumber) <br />Sketch(Detailed plans may besubmitted) <br />The undersigned hereby appliesfor permissionto !7xcavate,constructand/orothelwise encroach,on CountyHighwayRight-of-Wayonlhffsideof..approximately_---__feel/mile _ <br />of ,,'.by performingthe followingwork (desciiplionofworl(): <br />',Smrfn &ocJ::,+6Y)6 icU IUC....t)z:o p&DA,~~~+-:&/'+'\~.'..'. <br />I =~t=/ahv\L ~.@ACOlVl+if B10uf <br />Work will commence on or about D-JPr ap~xZ:iateIY days.\.7 I Ito .I,the undersigned,certify that I amthe ownerof the respectiveproperty,or am qualiiie.to eprese~the ownerandagreeto dothe. <br />work described above in accordancewith the rulesand regulalionsof SanJoaquin County and subjecllo inspectionand approval. <br />_d_1q I~lle~'_tJ-j Dale <br />fk\CEIiiRAl.SERVlCESlCJBlICAl.1PUS-SV,WKVAAS1ERPSlGlCROACllMENTPERMIT NruOA110N.COC ((l9J13)