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opo <br /> APPLICATInN FOR FROACHMFNT PERMIT <br /> PLEASE PRINT: <br /> Date 10/12/00 OFFICE USE ONLY <br /> To: San .Joaquin County JOH # REF 4 <br /> Department of Public Works APN CRV # <br /> EXP. DATE <br /> Geomatrix Consultants, Inc. VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> . AREA QUAD <br /> 2444 Main Street, Suite 215 TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> Fresno, CA 93721-2734 <br /> (City, state, Zip Code) <br /> (559) 264-2535 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Hignway xighc-or-way on 411= west aide of <br /> Cherry Road approximately 9,000 feet/MX& north <br /> of East Highway 12 1 Victor, CA , by performing the <br /> following work (description of work) : Tnmtal and develop a 4—inch diameter <br /> grnnndwater monitoricLCJ well to a depth of approximately 80 feet below ground <br /> surface Surface completion will consist of a traffic—rated vault. <br /> Work will commence on or about for approximately <br /> one dayN. <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 abov'm in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant - Title Dote <br />