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APPLICATION FOR ENCROACHMENT I'lERMIT <br />DRIVEWAYS: <br /><;-5QUAD <br />OFFICE USE ONLY <br />JOB#71(}()Z7 REF# <br />APN CR# <br />EXP,DATE (!J -/~(h <br />.VALID TO fO-H6 <br />STREET <br />AREA 0TYPE <br />FORMS <br />NOTES <br />PLEASE PRINT: <br />Dale l2J.'11/(t2 I <br />To:San Joaquin County <br />Department of PublicWorks <br />CA 1-1 E()R,iO/A viATEf?.c"-SE(U.'J li!.-E.(Applicanl Name) <br />11.00a E I--J1FA IiETiE ST <br />(Mailing Aqdress) <br />_<:'11 '''ToN 11",qS~5.~T()vl'-(J1.... <br />(City,Slale,Zip Code) <br />'d..o0\4 to Lj -ca-3 J l~.__~:J(Area Code.Telephone !'lumber) <br />Sketch (Detailed plans may besubmitted).~ <br />"~~U& <br />The undersigned hereby appliesfor perl1iissionto excavate,conslrucl and/or olherwise encroach.on County Highway Right-o~Way on <br />the l'"f-'+side of ()-r(:>approximalely .e ile S:lu:th <br />of :-""-"-ffi '...,,by perfonmingthe following work ciiption of work): <br />t,..Work will commence on or about ~pproximatelY days,9 I 11.0 <br />I,the undersigned,certify Ihall am the owner of the respectiveprope ,r am qua fled 10 representthe owner andagree 10 do the. <br />work described above in accordancewith Ihe rules and regulationsof San Joaquin County and subject to inspectionand approval. <br />.M:\CENTlWSERVlCEStCl.8'lICAl.'IPlJB..$V.WKIMASTERl'SIelCROACHMElITPERIllIT APFl.ICA110N.OOG (1l9/13)