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JUL '.) 5 2012 <br /> FRESNO <br /> E:SNO <br /> APPLICATION FOR ENCROACHMENT PERMIT MIS/DPD <br /> PLEASE PRINT: C`pt bo Q ?,-7,5 <br /> go <br /> Date y IZ,_ OFFICE USE ONLY <br /> To: San Joaquin County JOB# !352-/93 REF# <br /> Department of Public Works APN g CR# <br /> EXP.DATE //57&S <br /> �LFC77t( L VALID 3 ,�! /3 -k 3 DRIVEWAYS: <br /> (Applicant Name) STREET F J> <br /> AREA QUAD Ale- <br /> 72f-L w A7-ic.i2- (2-to TYPE ole 1 <br /> (Mailing Address) FORMS C5 <br /> NOTES <br /> (City,State,Zip Code) <br /> 9 I(6,7(00-2926— r LCRA1V- ScaFP1� I <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE A �-lE►� RoRv3 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-W y on <br /> the 6:N6 side of 81ZU E'C-J-A-- 0-0 approximately- fe o� <br /> of_ lOEDT 2D. by performing the following work(description of work): <br /> PoLf- A-c7L-4A1S1t-'Ty ISSves <br /> Work will commence on or about W,31 1 I for approximately I 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 /> '7-z Z o/ ? <br /> Signature of Applicant-Title Date <br /> E:1PUB-SV.WKUMSTERPSIENCROACHMENTPERMITAPPLICATION.DOC (01M) <br />