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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date --March 9, 2010 _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public IJV'orks APN CR# <br /> EXP.DATE 7 771-5-71e-, <br /> Fred Van DyVALID __VALIDDRIVEWAYS: <br /> (Applicant Name) STREET <br /> PO Box 607 AREA QUAD <br /> (Mailing Address) TYPE yr?��Vx <br /> FORMS <br /> Lockeford, CA 95237 NOTES <br /> (City,State,Zip Code) <br /> L <br /> Area Code-Telephone Number) <br /> F <br /> Sketch(Detailed plans may be submitted) <br /> See attached plans. Shaded area on plans is area of encroachment. <br /> Fhe undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-ol'AAlay on <br /> the -North--- , side of Cherry Street extended approximately_____ ___Aoo fee <br /> i_ <br /> Uy pelf"'i-i'n-iny th101iovVing W01'r, (deScfip tion of worK): <br /> To grade and pave a road. <br /> commence- _o__n or about o—ut <br /> Work will — June, 2010 for approximately 3.0- days. <br /> 1, the undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree do the <br /> described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> work do g cc to <br /> 5 <br /> Signature of Applica(ftL Title Date <br /> I 1� NKWAS;ERPSTNCQ,)',C I I!Af Ni PERNO A PPUC",Ti0N.D11C (01x's) <br />