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2095781974 M St.,Modesto Ca 03:01:19 p.m. 06-18-2008 2 3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �(�"!fS �+ ,yOFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # _ <br /> Department of Public Works APRT C # _ <br /> /J EXP. R" <br /> DATE <br /> 7- VALID l"/� TODRIVEWAYS: <br /> (Applicant Name) STREET �TCf�El/EP,�°Jr <br /> AREA'?J.9 Y QUAD / * _- <br /> �i/�D TYPE <br /> r(Mailing Address) FORMS <br /> FORMS /���2i <br /> -D/.t 1711 44l 5.L.l 0 NOTE <br /> '�`� <br /> (City, State, <br /> ' iS�tate, Zip Code) <br /> _ f0 1 15 D -72C?,,, <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Ice f GG•, t,�-c�',c.��-� <br /> The undersigned hereby applies for permission to excavate; construct 'and/or <br /> otherwise encroach on County Highway Right-of-Way on the -f side -of <br /> approximately 1 feet mile <br /> -of- by performing the <br /> f�ng work (deO�at:ion o�work) : f�j <br /> #' <br /> A T2s c eta <br /> Work will commence on 017 about (0- for approximately <br /> days. <br /> 1, 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 /> Si atur of Applicant -• le Date <br /> MAS2'dA-PS\P3BSCFD:. (6/CO) <br />