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(2UI`�Z <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> PM 309-54.38,8 <br /> Date /2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# Vd66,9 6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / /5 y <br /> EL CC7,,Zlc CCi VALID 70 /!S IZ DRIVEWAYS: <br /> (Applicant Name) STREET AMA / <br /> AREA FSeAta,l QUAD 15�5 <br /> FRESNO RAI C/ DMI? TYPE <br /> (Mailing Address) FORMS <br /> R/_1/ gA5T. NOTES <br /> rME SN®, CA, 9:3 '720 <br /> (City,State,Zip Code) <br /> 5a.�a 34-1- 53// <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> o � <br /> 56- A T7Ae-/�9C.,C) <br /> V8-r1114- PW&15, <br /> 15. <br /> PM 3053a <br /> $ 4 L9 <br /> ® SANTA ft:RD(CO MY 0) <br /> SAMA FE RD(co HP1YV)��,r <br /> T-T—STAT.� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway-Right-of-Way on <br /> the r—A 3'' side of 5AA.I rA / t 1QoA � approximately.2 /p tfe l�nile N W <br /> of CVSdam.' 1s' ACJ F—S c A L O h/ —,by performing the following work(description of work): <br /> 1.TRENCH/BORE AND INSTALL(2)HPR-TYPE Cf1 OMER STATION <br /> 2. TRENCH/BORE AND INSTALL 2W OF 2'HP SIFEi.WN <br /> 3.TRENOH/BORE AND INSTALL 162:OF 2'HP PLASTIC LWN <br /> 4. REPLACE AND TRATaM(2)SERVICE TO NEW I,WN. <br /> & TMO/EXCAWE AND RE>,X(3)OaONET?HPR SEES <br /> 6. CLEAN AND RESTORE AREA TO ORIGINAL CONWION. <br /> Work will commence on or about_� •6 I 1 /2 for approximately_ D. days. <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 /> .17541V1®2 aA16lv•/65r1111AT0,A,- 6- /Z <br /> Signature of Applicant-Title Date <br /> (SBO) 89.9- .3151 <br /> E�PUBSV.WKWASTEPJ'a'NCROACHVENCPEf WAPPUCATI0N006 COJW) <br />