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209 9527381 8-mile enginerring 10:14:11 a.m. 08-27-2012 1 /1 <br /> • rKx k-,ll i U W14 AAv, L ffw-)vN d lcl/ r<- <br /> PS- 1Z°Za�:7-� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date a j 21/11- OFFICE USE ONLY <br /> To: San Joaquin County JOB# -1,S(3-1 9-- <br /> S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S- Z 0/z- <br /> �VI MM,11;5 ATAT VALID + p! TO `j-/S-Za/, DRIVEWAYS: <br /> (Applicant Name) STREETAREA QUAD <br /> sem_ <br /> Z3OO • �IG ��- TYPE PIA-. _ <br /> (Mailing Address) FORMS S-' ww- tzq <br /> �r�T o % CPj- 9 S2-j o NOTES <br /> (City,State,Zip Code) <br /> (2-M) L+?N-Lf2(4? <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitte ) <br /> IG04WVV <br /> A` Qclsn�1G- M <br /> -a #. ` �- aolrrr PoL£ <br /> ?A0. 2-DI-3°l- 02C. PAIL 2'9-alb -1)21 ZF----- <br /> 2357gS 12D <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the \J�lfrS'T side of `-1�l approximately ' fee ileo <br /> of_Th3�5- �2��, by performing the following work cription of work): <br /> rJ L <br /> � - L <br /> .3410T POLF- AS N . PMCE CABLE A14D WIPE Iw1 TOCOC14 MW '9b" CiJUI"� <br /> Work will commence on or about for approximately �S 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 /> Signature of Applicant-Title Date <br /> EPUB-SV WKWASTER.PSENCROACNMENT PERMIT APPLICATION DOC(01M) <br />