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2095751974 M St.,Modesto Ca <br /> 01:03:01 p.m. 11-06-2008 2/3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> r�OFPICS USE ONLY <br /> To: San Joaquin County JOB # / !�l <br /> Department of Public Works REF # <br /> APN CR' # <br /> :1 <br /> A-F t r EXP. DATE 1Z•1�O$ <br /> VALID •t!�•Ct TO 1�•h_i•OQ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AI 60 m tom/le, AREA - y QUAD <br /> o <br /> (Mailing Address) FORMS <br /> QQy 063 NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> fCAD*_ <br /> The undersigned hereby applies for permission to excavate;,.cgnstruct and/or <br /> gO rwis e croach on County -Highway -Right-of=Way on the V 6fapproximately side of <br /> ee /mile <br /> follow'ng w k (descript:ion of wo k) : ;rforming the <br /> t C( d1Q ep i <br /> � C „ <br /> Work will commence on or about B I f)IncA <br /> days. for approximately <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 /> tatur of Applican _ 7. le �' hlS54 1�-1+w�~ Date <br /> SS$(7IDL (6/00) <br />