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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 11/25/01 OFFICE USE ONLY <br /> Date <br /> To San Joaquin County Jos #, / I DoE REF # <br /> Department of Public Works APN CR # <br /> EXP DATE LI-9Z— Of <br /> Wn StEmGeo-H riea s VALID 7_­?_0j To DRIVEWAYS: <br /> (Applicant Name) STREET M ,SSI'on 6Ve <br /> AREA QUAD G C <br /> 1386 E. BeaTEr Street TYPE <br /> (mailing Address) FORMS — <br /> NOTE <br /> W,oad1a'6 CA 95776-6003 <br /> (City, State, Zip Code) <br /> (530) 668-5300 <br /> (Area Cocke - _Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See Attached Figtiu-es <br /> NOTE The San Joaquin County Environmental Health Department permit # for the <br /> Geoprobe borings (TPH3) and subsequent monitor well MW7 is SR0024869 <br /> k <br /> 0 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-w4on the WMI side of <br /> AWjcn Ave. approximately 100 eth <br /> e mile si <br /> of the SW corner of gal= Club. BINd. and Morn Ave. , by performing the <br /> following work {description of work) us direct t (truck =Lnted ) advance <br /> t llect soil &holp- es for of the proper locatim <br /> tn w�11 oarrr a i, -te 20' sash of tY znter.�tacn and end <br /> th- in <br /> ticn. The test holes w-LU be destroyed with (neat rfzt � 5% <br /> Work will commence on or about _ & for approximately <br /> 1-2 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 Joaquin County and subject to <br /> inspection and approval. <br /> 42 2 <br /> ignature of plicae - ofitie Dat <br /> "ST0t psNa' umt (6/30/001 <br />