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APPLICATION FOR ENCROACHMENT PERMIT <br />OFFICE USE ONLY <br />JOB#I/OfXJ'5'REF# <br />APN CR# <br />EXP.DATE (g/~ <br />VALID ~It,-,TOr~blJ?DRIVEWAYS: <br />STREET AZ ~£,eO,I • <br />AREA E.t><-A,4?.¥QUAD IlillllJl-SE • <br />TYPE -tiM/!1WlJ?~$lk~(".d.• <br />FORMS ./"' <br />NOTES <br />\~O '6 FP-A7...a!...AJ5 <br />(Mailing Address) <br />PLEASE PRINT: <br />Dale GPI.d.-J /20110I <br />2£AQ.Y,s.,#J \j r ~Cj L\'6 \ <br />(City,State,Zip Code) <br />"l,5 -3Sl,.-O\O-~ <br />(Area Code.Telephone Number) <br />To:San Joaquin County <br />Department of Public Works <br />~OA-{:l 5A.f£"\~<....~S;r. <br />(Applicant Name) <br />Sketch (Delailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High~Right-ot-Way on <br />.the'o'e:r 1W+sideof £1'6'--12.:,,02 1S-~approximately 60 dWlmile wE;'5r <br />of SwrP.f'e ~.~~~~~~~,by performing the following work (description of work): <br />.-n ;-1st"V--J\l \rWoJV~0"\ <br />5AJ"f5 --\IU\<-M<'S Dib "I.....--r;...c: <br />Work will commence on or about for approximately days. <br />c;.,/:l.l/)b <br />DateSignatureofApplica <br />I,the undersigITed;-G ify that I am the owner of the respeclive property,or am qualified to represent the owner and agree to do the <br />describe ove in ccordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />E.\PUB-SV.I'llW.lASTERPS\EIICROACHMEIIT PERMITAPl'UCATIOIlDOC (OWB)