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PLEASE PRINT: <br />,;":'"l~.:';~l:.i..__. <br />APPLICATION FOR ENCRoAcHMeN'P'PERrIitlf'UiI,:.c:\J i'i I Y <br />2016MAR loAM 8:I 2 <br />.:"',-r)"r i'-',':C';;;::1'1 1("''10 'r,':;;~~..bFFICE USE ONLY <br />JOB #//a::i:6 REF# <br />APN I •CR# <br />EXP.DATE /J1t /IV;? <br />VALID 7~''TO {J11jJ(p DRIVEWAYS: <br />STREET I Jh$/!/J,I • <br />AREA /L!W QUAD IIW • <br />TYPE '~• <br />FORMS -Z_'f'w.,e...:z1 <br />NOTES / <br />, <br />Date <br />0/1/1 C/J 9S632 <br />(City,State,Zip Code) <br />l.o'J-fl/o ~f)O~/ <br />(Area Code.Telephone Number) <br />JC,I1fi!w{l)r-e chd,et <br />Sketch (Detailed plans may be submitted) <br />To:San Joaquin County <br />Department of Public Works <br />V19.G.I~~t1 J;/1 D tlSf'/Z/-:s Em:-- <br />(Applicant Name) <br />/1 J fLs £.sh//<lZm fJI"K' <br />(Mailing Address) <br />Ov",Z;€.~.f..-"",nor..:,,-t-,'",,-v://i3e-:"':cJ,Ad,.J.PJ.il/frs,ir At <br />JfS"''iltJ w:1I:.d.wI1Y /2 <br />L£.1f}:t ell.rS-Ji/:L <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way onthesideofapproximatelyfeetlmile_ <br />of ,,by performing the following work (description of work): <br />I3M~Ifao,ss U1v/.•£,(t3Hz'dM-r4.,.f L/'qdD P/f./J,jL.e;I.r j?/,4,,,- <br />J -{"pl/t .r/lf./yM/~'"I.:••,f&"\1='.•4.C TO k--rf.sC S;'p",--<:PI-~. <br />Work will commence on or about Z3 ?,-l'6 for approximately days. <br />I,the undersigned,certify that I am the owner of the respective property,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 />.-4 (J""ne '"ti~1'1YlA e-e..Signature of Applicant.Title 3 -IF'6Date <br />E:\PU8~V.WKWASTER PSIENCROACHMENT PERMIT APPLICATION.DOC (01108)