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02/13/2013 14:57 2099316403 IDC LINDEN PAGE 01/01 <br /> AlJ► CC>6 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:, <br /> Date 2/13�12> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE It P3 / <br /> &C'� Q'Ilet 1 VALID 1 (? 3 I DRIVEWAYS: <br /> (APPnt Name) STREET <br /> AREA � QUAD A45 <br /> TYPE ALL P/- <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed pians may be submitted) 41\ Sv1\ �c ,� 6 X\jCt <br /> ev i`. wy v�vr - <br /> 7�?7tp C <br /> "IN <br /> OVA <br /> { <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hig;( egscnpt?i'gt-o#Way on <br /> the side of �i►s approximately 2.6&50/ l <br /> Of_� �r �� ,by performing the following work on of wl�rk}: <br /> Work will comm nce on or about 15 ew— M-,Avck for approximately r day,0• <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 /> 1 t3 <br /> Signature of Applicant itle Date <br /> G.TiJ94V.WMMOTGRPSENOROACNM24TPFAMTAPPLIWION.000(MA) <br />