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i <br /> APP� 'A TION FOR ENCROACffi4EN'r pEFMiT <br /> PLEASE PRINT• . <br /> 3 2D OFFICE USE ONLY <br /> Date <br /> JOB # //D D REF # <br /> { To: 5�? Joaquin County CR # �f36S�Z. <br /> Department of Public works APN <br /> r EXP. DATE <br /> �rrJ ,QQ-'��7 rl�G�,$ VALID '`1-9-U/ TO -IS`'DI DRIVEWAYS: <br /> � — 11 lS d'loll/ .4dE <br /> (Applicant ame) STREET <br /> AREA[ 6CXZ QUAD Cm. <br /> GszfBt� TYPE ��hoN/TO•er,✓Gi u1 _ <br /> (Mailing Address) FORMS SS ��✓ <br /> NOTE <br /> 9,517 /o-Zo 3 <br /> (City, State, Zip Code) <br /> �--)- <br /> (),rea Code - Telephone Number} <br /> Sketch {Detailed plans may be submitted) _ <br /> Sly4p2 5` lv 8 � 9 . <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-way on the side of <br /> • approximately eel mile s/�u <br /> offie_ G11 n rLty performing the -/ <br /> followiing work (description of work) : ti �e _`/ <br /> .'57cp ii ,( <br /> LAN <br /> Work will commence on or about or. approximately <br /> days. <br /> z, the undersigned certify that I am the owner of the respective property. or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> i inspection and approval. <br /> 40"e?00-rele Ile, <br /> Z4 <br /> Signature £ Ap 1�' a-n-t- Title <br /> '-'dTMPS�T8VSCEML 16/30/001 <br />