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APPLICATION FOR ENCROACHMENT PERMIT <br /> rF-A E PRINT: -� <br /> _p L L� <br /> Date Z�2-0 Z OFFICE USE ONLY <br /> To. San Joaquin County JOS r„f1 SDS REF # <br /> Department of Public Works APN CR' �2 <br /> EXP. DATE -o I <br /> i��SrL✓� UCG` /IJ��V� VALID 11'9'01 TO �-���`� DRIVXKAYSs <br /> (Applicant x ) STREET AIJSr0n1 44,1 <br /> r AREA ?'7-Cc.ic7z'A.( QUAD CC- <br /> 7'- <br /> IG/ rJeGe✓l1e, TYPE MrNiToieln/exr 4dELL <br /> (mailing Addre�so) FORMS V 1—W _ <br /> 7 S�/ZiGu� NOTE <br /> {City, tate, Zip Coda} <br /> (jrxea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ✓OG�;esi 7 `-'�e.�/J/�ji)vy/phi•J?F {S� <br /> �TCd 11t lZe <br /> Y <br /> The undersigned hereby applies for permission to excavate, const ct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximat ly fee /mile <br /> of ,�� r1� .+r 4Er o /l9:�i�' IA- Y Performing the <br /> i <br /> following work (description of work) : <br /> Liz <br /> work will commence on or about for ap roximately <br /> days. <br /> I, 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 Soaquin County and subject to <br /> inspection and approval. <br /> ��signature of pplie - Title Ra • <br /> "u>�.ss\rsnwm. uholeo� . <br />