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V/ <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6 ,2 1 -12 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOS# <br /> Department of Public Works AP7✓: 0 p3'Z'�REF# <br /> N CR# <br /> EXP.DATE O / /2 <br /> -- f'R C��/� �•�5 E L EC'Ti�'��' CO VALID <br /> (Applicant Name) STREET TO 2— DRIVEWAYS: <br /> AREA <br /> UAD <br /> C. TYPE Q� <br /> (Mailing Address) FORMS ---_ ; <br /> 49 R/U,6R . PA/�f� F'I/I44 SAS NOTES <br /> 9 3' 'a o <br /> (City,State,Zip Code) <br /> '(5595 .34- - 53a <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 47 rrA6f/&1-!_7 <br /> VI SlR.C, TU SNC <br /> r AIV 39/ <br /> 72 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High Right of--Way on <br /> the x'/15� side of ��NrA FE 2aAn �y <br /> of -5'E//V0 F/Z approximately 5 U smile N kV <br /> by I. TRENCH/BORE AND INSTALL (1) HPR-TYPE DISTRICT REGULATOR STATION mg the following work(description of work): <br /> 2. TRENCH/BORE AND INSTALL 20' OF 2" HP STEEL I,4AIN <br /> 3, TRENCH/BORE AND INSTALL 1251--OF 2" HP PLASTIC MAIN <br /> 4. REPLACE AND TRANSFER (4) SERVICE TO N511 I,LAIN. <br /> 5. TRENCH/EXCAVTE AND ROAOVE . CUSTOMER'HPR SETS <br /> Work will commence on or about duly __20 2 a/ <br /> for approximately N/NST y days. <br /> I,the undersigned,certify that 1 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 /> 5,CNlor< 6,Z • I2. <br /> Signature of Applicant-Title <br /> .556 - 469 9 • 3/5/ Date <br /> ENUBSV.V4WAStMPSf1,'CROACKN PERwAPPl1CAT,a.tDOC(0Lf6) <br />