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\\\ <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date -J/cL-"1!1 Co <br />To:San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />'-toY!>L<.k.>f-L,u <br />(Mailing Address) <br />~b CJ4 qS"'UJt <br />(City,State,Zip Code) <br />OFFICE USE ONLY <br />JOB #23000 REF# <br />APN CR# <br />EXP.DATE 6-{-{G <br />VALID 'l-i.2.-/t,TO 6..,t-lb DRIVEWAYS: <br />STREET 'ith I()It,.[Hj,• <br />AREA s1ock+an 'QUAD $"5 • <br />TYPE 1•••~1!C6 • <br />FORMS <br />NOTES <br />4CfV-?!t:.-IZ?,1 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />The under~igned hereby applies for permission to excavate,construct and/or otherwise encroach 9n County Highway Right-of-Way on <br />ft ~-ti--side of 9."""\/0"'"I I;>i'~u.approximately 5 ~mile _["oJ__ <br />of .$~,"'?h<,lc.~,by performing the following work description of work): <br />\-0 G.c.'"",.I',~ <br />Work will commence on or about for approximately days.---------'--\". <br />I,the undersigned,certify)han-am the owneH!rthe respective property,.or am qualified to represent the owner and agree to do the <br />work described abo.ve-inaccordanc -witilthe rules and regulations of San Joaquin County and subject to inspection and approval.~- <br />, <br />~Signature of Applicant -Title <br />E:IPUB-8V.WKlMASTERPS\ENCROACHMENT PERMIT APPUCA TION.DOC (01/08) <br />'-j".---,.r--o