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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date A r i l 3 0 2 013 <br /> �t*lP��p�7(�� REF# <br /> To: San Joaquin County JOB# RE <br /> Department of Public Works APN # <br /> EXP.DATE <br /> Preston Pipelines, Inc. <br /> VALID , --1 Z-2�r3 TO G'�IS-?.�► DRIVEWAYS: <br /> (Applicant Name) STREET �o�,� <br /> AREA OL^-, QUAD S <br /> TYPE � � <br /> oA' <br /> 133 Bothelo Avenue 2 <br /> (Mailing Address) FORMS <br /> NOTES <br /> Milpitas, CA 95035 <br /> (City,State,Zip Code) <br /> 408-262-1418 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach onCounty Highway Ri ht-of-Way on <br /> approximately 0.4) fee ile vW i� <br /> the �or��1 side of t�cr�c � t��, NN y <br /> �,, 2 c��o ,by performing the following work(description of work): <br /> of r, 1tn�, lg�ttQ 1 { �r 1Vic: �� r <br /> ivn �t,,eet <br /> Work will commence on or about for approximately 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 accords e with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> fir;.. April 30, 2013 <br /> Signa ur f Applicant-Title Date <br /> E:IPUB-SV.WMMASTERPSIENCROACHMENTPERMITAPPUCATION.DOC(01108) <br />