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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12/3/ Z,W� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2`e.n. is 2,061 <br /> VALID Tay, 5 ,2xxJgTO Tien, 15, zeio9 DRIVEWAYS: <br /> (Applicant Name) STREET Weji, IZ4 <br /> �? / <br /> AREA �,� _ QUAD 5t.J <br /> b7�_ TYPE <br /> t (Mallin Address) FORMSo <br /> _�,.Zg <br /> D, NOTES <br /> (City, State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> i <br /> The undersigned hereby applies for permission to xcavate, construct and/or otherwise encroach on County High Right-of-Way on <br /> the CSS _side of U✓�)g� �i approximately l Oct f ile Wirth <br /> of i (tj� t/�r1ot)'-S C�—, by performin�;A <br /> following work(description of work): <br /> S a C i t l)O t%1C� 1 ern� a 'wV-1 0� U IcQt>I- <br /> &:)I1e-c 0 Ik I <br /> I rr� F`! 7fS450 .0 <br /> C, ! c 4I4 C. <br /> iAStr) hyA� Cert--14 . <br /> Work will commence on or about — O'VMLI r _2001 for approximately 1 V2—. 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 /> 12/3/ <br /> Signature of Applicant-Title Date <br /> E1PU&SVWKMkSTERPS%ENCROACHMENTPERMTAPPUCATION.000 (010) <br />