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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE -PRINT- <br /> Date <br /> LEASEPRINT-Date 91� 4 OFFICE USE OIQLY <br /> To: San Joacruin Count", JOE # '130552-co REF # <br /> Department of Public Works nnN CR K <br /> EXP. DATE I 1 S' <br /> _l <br /> VALID / 3 d�0 TO Olv DRIVEWAYS: <br /> (Applicat Name) 6PR�LT J^z7'A` II�N%1 D1L <br /> AREA STkA/ QUAD <br /> _ailing Address) FORMS GULy, e z <br /> NOTE. / <br /> (City, te, Zip Cod ) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> _ �Q <br /> CiE�~ <br /> The undersigned hereby applies for permission to excavate construct and/or. <br /> therwise eperoach on County Highway Right-of-Way on the side of <br /> ►�; approximately feet/fie <br /> of (`" by performing th- <br /> followi g ork (descripton_ofw rk) e <br /> 5� c <br /> Work will commence on or about for approximately <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 Joaquin County and subject to <br /> inspecti and app val_ <br /> SlyuatUr— Gi AppliCa,i - TitI i'atc <br /> FST�,.pS,,F� sus eioo, RETURN PERMITS TO: <br /> PG&E <br /> JOB PROCESSING DESK -BLD 1 <br /> 4040 WEST LANE <br /> c-rnl-wrnhi f-& Qr,-)nA <br />