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APPLICATION FOR ENCROACHMENT PERMiT <br />PLEASE PRINT: <br />-:,sTO ~ILTbN (2A CfSOlDS <br />(City,State,Zip Code) <br />~doq)Lf Lo Lj -B;,3 j I ' <br />~(Area Code0 telephone[\lumber) <br />Sketch (Detailed plans may be submitted) <br />To:San Joaquin County <br />Department of PublicWorks <br />CAL!r':'Df2Jo}A WATEl?.cjftil/jI~E,(Applicant Name) <br />I~aa E I---AFA\U~T1'E ST <br />(MailingA~dre55) <br />DRIVEWAYS: <br />OFFICE USE ONLY <br />JOB#7lc)Q 77 REF # <br />APN CR# <br />EXP,DATE 8-1>-Ih <br />,VALID '>-q '{6 TO f5 -{5 -/{, <br />STREET [CZ:JJa'13+0 <br />AREA Ht{a;:QUAD ~)-.£,~__ <br />TYPE to €1<1(;h <br />FORMS 5 $wtr '/Z.'L9 <br />NOTES <br />Date <br />,', <br />The undersigned hereby applies for permission to excavate,construct androrotherwise encroach,on County Highway Right.of-Way onthesideof''approximately feetfmile _ <br />of ,,',by performing ihe followingwork (descriptionof work): <br />o ~:_fr''/1 0 <br />Won,will commence on or about 1.2.-.~or approximately days. <br />'7 I }(pI,the undersigned,certify that I am the owner of the respective propertY,0 am alifled to represent the owner and agreeto do the. <br />work described above inaccordance with the rules and regulationsof SanJoaquin County and subjectto inspectionand approval. <br />:\CEWRA!1iERvlCESlClffiICAl\F'Ua.s\I.WK1MASlER.PS'a'CROACHMsrr PERMrTJlPPlJCA110N.DOC:(09113j