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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date il',25 _DL OFFICE 'USE ONLY <br /> To: San Joaquin County JOB # 7 3,0 5-Z- G REF <br /> D artment of Public Works PSN CY # <br /> EXP_ DATE <br /> n VALID V TO I0 /S oe, DRIVEWAYS: <br /> _ ._ <br /> J — <br /> (Applicant <br /> — <br /> (Applicant Name) STREET F1104 6 <br /> AREA E foRD QUAD A125 <br /> 110 yU ZJZ S T LOA-1l5 TYPE -772ENClrl A r-2 <br /> (Mailing Address) FORMS f4&2�J. <br /> NOTE <br /> aSiDCIKMAJ Cl4 4B 2D 4 <br /> (City, State, Zip Code) <br /> ODS) 9y241/178 <br /> (Area Code .- Telephone Number) <br /> C3 N <br /> Sketch (Detailed plans may be submitted) ° 4� <br /> mom <br /> -v <br /> -- <br /> x� w <br /> /Pi19 -30-3.37930 <br /> The ,undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the EnST side of <br /> ELm STREET approximately /05 feet/came <br /> of 1-1141"VI9DA/1> aS7. LDGKEFOQL') by 'performing the <br /> following work (description of work) : <br /> J.A/S Tl4L L <br /> LASJ ELEC}`lL/C� TELEPltDIJL <br /> "AJL TL ,ertclLl TIES 23V DPE,u 7ZZA14-1V1X1,6. <br /> Work will commence on or about J7aAA6 /,..2004 for approximately <br /> Z20 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 /> v - �2 L-�IS QST/rrli9To2 `7'-25-06 <br /> ,.,afore of <br /> Applicant Tule RETURN PERMITS TO Date <br /> �/'� p�� PG&E <br /> MASTER.PS\FEESOML (6/00) JOB Q&W DESK_BW <br /> 43TOCKTOM, CA 95W4 <br />