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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 12-6 -2010 <br /> Date 12-6 -2010 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 30bS2- REF# <br /> Department of Public Works APN CR# <br /> p� EXP.DATES t: <br /> 1 4 E VALID 11-1 3 ;6 TO a i r= DRIVEWAYS: <br /> (Applicant Name) STREET LelEs-F- <br /> AREA -Sn^1 QUAD „/ <br /> S 9IVER PARK F.. EAST TYPE rbr- K <br /> , O24-P4.A*+.3,.T <br /> (Mailing Address) FORMS ss �,,4,.) <br /> FRESNO, CA 937Z0 NOTES <br /> (City,State,Zip Code) <br /> (559) 347-5246 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE AVIACIAE1? XeRHE_S <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 40ESr side of Log-Tr LArJEapproximately ._..#eebmlYe r�-ouT <br /> of E"% r'r- ,estJL� ,ems 7a7S7 7d�+r "7V L1�/�lI7'S by performing the following work(description of work): <br /> RUUTWE REPAIR f REP(4(LM6kT 6F OUI`RH&U 1 UND�RGROUAID fLECTpje <br /> EQUIPMENT ON EXI5TIM&POUS AN IN WPM, RIUCLOSURES AT LQCIITIDIU� �!r'1lotrS <br /> Work will commence on or about , - 1; Z(9/,O for approximately days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -... 0 0 e. X�:-1-- jg-ff-r 2o1J <br /> Signature of Applican Title Date <br /> E1PU&SV WKWASTERPSIENCROACHMENT PERMIT APPLICATIONDOC (01/00) <br />