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APPLICATION FOR ENCROACHMENT PERMIT <br /> f4. PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date JOB # REF# <br /> APN - CRV# <br /> r.To: San Joaquin County Highway Department. EXP. DATE <br /> VALID 5-5- TO DRIVENVAM: <br /> ADVANCED GEOENVIROMMEN'TAL S1vC. STREETI iW-. ; <br /> (Applicant Name) AREA QUAD 1� ' <br /> TYPE�.,a�1-& s <br /> !631SHAW P-DAD FORMS <br /> y (ri?ailing Address) NOTE <br /> x STOG.kr6N . cA 95215 <br /> (City, State ZipCode) <br /> (20q) 4167- 100(. <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> >_¢ PLEASI= SEE ATVAC1-1Ei') y.luRK s SAN DATEI.) 15 "SAjAQAPY 20(71 " <br /> `Ta <br /> s <br /> ' The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County <br /> I-ighwayRight-of-Way on the NoKTH sideofFLM -, -rte �ye�yvE approximately <br /> lgr)- t(.Q /mile N ,gTy of ;I1'3 c ,, Nj&r ( C n by performing the <br /> following work: (description of work): z 1\S—F-ALl A-rr c M c'v 2-- T-N C" v./C C ,I�'v E RE n <br /> Y. <br /> 'ATF p MU NZTC>2L1�L(- W F L 1 MW 10% (ScREFNF n ?'ETv FFIQ <br /> 4C) Q CKD Fti=_cr) tg1-4p -r- - IF) (-s'C 91 cvy C- 1`1 RETW EF 10 ,a r411 <br /> Work will commence on or about Ae Q-L L a hga ?go"] for approximately ?,O days. <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br /> t agree to Jo the work described above in accordance with the rules,regulations of San Joaquin County and subject <br /> c 1' to inspection and approval. <br /> 5"i A F F ``CS F N S 1 ? / l .3 /c) -7 <br /> fx <br /> TITLE DATE <br /> SIGNATURE/017 <br />