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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />'Date ~J3-)6lO)(p <br />To:San JoaqUin ounty <br />Department of PublicWorks <br />Ce uf-C)f2JO}A viATEf?-0E~IZ...LJ )Q.,E,(Applicant Name) <br />I~aa E ,I--AFA\.jEnE ST' <br />(MailingA~dres5) <br />~STa Q-\L.TO N 6q QS0105 <br />(City,Stale,Zip Code) <br />'d-og~if jo Y-'2;3 iI,~(Area Code.relephone Number) <br />Sketch (Detailed plans may be submilted) <br />~,'r,dHB."\'/(),;;:G ~_:.:'••'--J ~['.:,OFFICEUSEONLY <br />JbB#710072 REF# <br />APN CR# <br />EXP.DATE ~~-{S~t ~DRIVEWAYS:,VALID '.$->{&TOO'(S-16 <br />STREET ~t c~v th /• <br />•~::~V;;QUAD f S • <br />FORMS S *QqNOTES <br />,-,-,-.... <br />,, <br />, <br />The underslg ed hereby applies for perni'ssion to excavate,construct andforothelWise encroach,on County HighwayRi9ht.Of.W~~ <br />the -side of 'approximately ,3QQ feelfrnile ,"2:J\ <br />of y-,,by performing the followingwork (desciiption of wort(): <br />?¥'\)~j)'H,I'o.1LLL...,.....;;~n.~"d'~-_ <br />~__LL ~42~U ']1030 0 ()::L (l,IA.-+:,?-!x 'i', <br />Work will commence on or aboul '~r approximately days,'3 IS-liP <br />I,the undersigned,certilYthatl am the owner of the respective prop ,ora qu liftedto represenlthe owner and agree to do the, <br />work described above in accordancewith the rulesand regulationsof San Joaquin County and subject to inspection and approval. <br />M:\CEIffiWSERVJCES\CL£RICAlJPU3-SV,WKVMS1ERPSlENCROACHMarrPERMlT APFlJCAllON.DOO {ll!i/13j