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2615NOV 17 PH \:38 <br />APPLICATION FOR ENCROACHMENT PERMIT GEI'T.l':,t'Hue WOP.:(5 <br />OFFICE USE ONLY.. <br />JOB#7~(lO~Z.REF #- <br />APN CR# <br />EXP.DATE'6-L:Tfi= <br />VALID .l:lL..:l..6--TO 6+(6 DRIVEWAYS: <br />STREET d&ln-/$Avt • <br />AREA Hrxt1ol1 QUAD ~J , <br />TYPE Bore • <br />FORMS (,$Ww ,€?q <br />NOTES . <br />.. <br />To:San Joaquin COunty <br />.Deparbnent of Public Works <br />f&iE I~3//2.38$6 <br />(Applicarit l\Iame) <br />qtll(tl Wes.~LAfte <br />(Mailing Address) <br />!dpak-fOf){!-A qs-~oLJ <br />(City,stale,Zip Code) <br />(~bCL'~73 -q'ls< <br />(Area Code -Telephone Number) <br />SketchlDetailed plans may be submitted)') <br />PLEASE PRINT: <br />Date 1/-/7-:lIP I> <br />.The unde~ned hereby applies for permission \0 excavate,construct and/or otherwise encroach on County Highw Right-of-Way on <br />the __~~__side of HA.rr I f Ave.approximately 50 emile N. <br />of LC'we-!I Ave..by performing the following work deSCription of work):,. <br />Repl«l!--€-.polr itfr :2"7"IIHA.u,'s ilve,$t=bclc.+o/ll <br />Worf<will commence on or about 12e -/It -2tJ 1£for approximateiy 1-=+0 days. <br />I,the undersigned,certify that I am the owner of the respective properly,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. <br />R.l)~ <br />Signature of Applicant -Title <br />ll-/7-~O/~ <br />Date