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412/27/2007 09:58 2094689324 SJCO PERMITS PAGE 01/02 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PL-WE_PRINT <br /> Date 3 - o U OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF' # <br /> Department of Public Works APN CR' # <br /> f ra rr'' <br /> EXP. DATE <br /> p C' 6 (�►� ,►i0,0 VALID TO 5 • - DR.TVFWA.Y9: <br /> (Appl cant Name) STREET <br /> AREA ltX P84 l 0-6e-QUAD <br /> � <br /> 7S Al, Cro # 25® _ TYPE G�t1caC <br /> (Mailing Addreas) FORMS `� t <br /> Wrd rI J CVe_e.tc 1 Cc -r#579LY NOTE <br /> (City, State, Zip Code) <br /> 2s- <br /> 774 y 33 o <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> F M:r'- } 75-14� <br /> l^3 <br /> The undersigned hereby applies 'for permission to excavate, cozy truct and/or <br /> othe wide encroach on County Highway Right-of-Way on the =i side of <br /> O pd M . W-34 approximate) feet/mile <br /> of 'be,..- n e !'t,„ (' , by perfo ming the <br /> follow_in work (description of work) EVA 10 " ! e- <br /> in5 M cr 5 t,,.3 cn�fV56�_- / !7 - /7 tL <br /> G I-e &orf_o ion <br /> Wor}S will commence on or about for approximately <br /> ;j <br /> days. <br /> 2, 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 /> 8ignatura o Applicant - Title Date <br /> IMSTSR.WFMCHM WOW <br />