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2095781974 M St.,Modesto Ca 12:49:15 p.m. 12-16-2008 2/3 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -40c6 OFFICE USE ONLY <br /> To: San Joaquin County Jon # r REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE _�• 0'7 - <br /> 1 J VALID /Z• .d TO /-/-5--07 DRIVEWAYS: <br /> (Applicant Name) STREET Af,,eor <br /> NI'll- AREA QUAD <br /> TYPE a <br /> / (Ma/iling Address) FORMS <br /> 0 ) (/drNOTES �/ Z <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be Submitted) <br /> The undersigned hereby applies for permission to excavate; construct and/or <br /> otherwise encroach on County -Highway Right-of-Wa on the L>!%! side of <br /> approximately r fe mile <br /> of GlLoG�S — <br /> by perf�inq�he <br /> f low' wor (description of wgrk} ; <br /> W 1 k�will commence on or about - - <br /> �� for approximately <br /> 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 /> Now ,� r ,� � <br /> at r of Applicant - i e <br /> Date <br /> rwsraR,PS\PRE$CfIDL (6/00) <br />