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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dale 3 G _7710E USE ONTLY <br /> TO: Sar_ Joaquin County JOB + 7. 57-40 REF <br /> Deoartmer_t of Public Works PDN CR 4 <br /> EXP. DATE �1 /'D 7 <br /> 61 y , VALID 6•ZS-o'7 TO '74-107 DRIVEWAYS: <br /> (Applicant Name) STREET' !'NEQ 2D. <br /> AREA G_1b_s QUAD <br /> TYPE AOZA, $d g. '7"W'6NGN <br /> (Mailing Address) FORMS .125("2, <br /> -- <br /> NOTE <br /> (City, State, Zip Code) <br /> (/z o <br /> (Area Cade - Telephone Number) <br /> Sketch (Detailed plans may be suhmitted) <br /> TRAFFIC t'ONTRG1_ P1_Ai\J <br /> SHALL eE AS PE+P <br /> /JT j�Z 3d(p3�C� CUPPENT M.U.T, C. <br /> CALIEOPNIA SUPPLEMENT <br /> RETLM PERWS TO- 1 <br /> JOB PPA=SSM MSK- <br /> 4040~LWW <br /> ST ON, CA 95204 <br /> The unde rsicmed hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Wary ori-the F4 Z::: E fS7- Sid Qs f <br /> approximately � ee /mile <br /> of `e/k�o h R , by "performing the <br /> following work (description of work) : 2 / L 6 <br /> rlGh f7- I'772,end 71 <br /> aCGe sS 17/� <br /> -F� i '�e Q,v.� a✓i92 f7S 2 l L �- / h o.,iC .r! - vJC`L o <br /> Work will commence on or about Z � o 7 for approximately <br /> 'O 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 /> �Z- 37ZO 7 <br /> Signature of Applicant - Title Date <br /> MASTER.2S\?3ES®L (6/00) <br /> a.`7 1` I' ) d ,_ <br /> i <br />