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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12-22-10 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1-up REF# _ <br /> Departmer,of Public Works APN _ CR# <br /> EXP.DATE /! lZ <br /> CITY OF MANTECA VALID TO 2 _ DRIVEWAYS: <br /> (,Applicant Name) STREET <br /> AREA � -SCA QUAD <br /> 1001 W. ENTER STREET TYPE —k%LCfAzN <br /> (Mailing Address) FORMS ssl j <br /> NOTES <br /> MANTECA, CA 95337 <br /> (City, State,Zip Code) <br /> 209-456- 8427 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Improvement Plans enclosed. <br /> City Contac :: : Fernando Ulloa 456-8427 <br /> Engineer Contact : Tony Marshall, MCR Engineering 239-6229 <br /> The undersigned hereay applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the both side of Woodward Avenue approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence cn or about 2 for approximately_ 420 ( <br /> I,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 /> A <br /> h () <br /> Signature of Applicant- itle mcie ,f4r j Date <br /> E9TUB-SV.WKVMSTER.PSIENCROACHMENT'ERWTAPPLICATION.DOC (01108) uf <br />