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^jjdj n"i „ 21 FAX <br /> I�UU1/UU3 <br /> it <br /> PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date 12-05-07 <br /> To: San Joaquin County-Highway Department OFFICE USE ONLY <br /> 10B#�qi REF# <br /> PG&E <br /> liAPN 249 - 050 - 09 CRV* <br /> (Applicant Name) EXP. DAT$ � — — - <br /> i -lam . <br /> 1524 N. CARPENTERRD. VALID 12-Z ;TO _t -r DRIVEWAYS. <br /> (Mailing Address) STREET ' tm, � ADS <br /> , <br /> MODESTO AREA ��' UAD CA. 95351 TYPE-F�'�,L Nock <br /> (City, State,Zip Code) <br /> NOTE <br /> 209-576-6603 _ <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans rcay be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on <br /> County Highway Right-of-Way on the 1~ side of S Santa Fe Rd. <br /> approximately 265' feet/mile N of Hall Rd.. <br /> the following work: (;description of work): 4'x4' Bellhole & 4' of y 110" wide <br /> trench <br /> Work will commence on or about 12/20/07 <br /> days. for approximately <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the <br /> owner agree to do the work described above in accordance with the rules, regulations of San Joaquin <br /> County and Subject to insp tion and approval. <br /> S Na OF APPLICANT -TITLE d� <br /> DATE <br />