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PLFASt; PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br />Date - mss <br />To: — OFFICE USE ONLY <br />Ban Joaquin County <br />�Pariment of Public Works JOB 0 _ REF N <br />PGE APN _ CR q <br />EXP -DATE <br />(AppIIWM m) VALID TO DRIVEWAYS: <br />31 STREET <br />Boeing WaY AREA QUAD <br />(Mailing Address) ------- TYPE <br />FORMS <br />Sleben Ca, 95206 NOTES <br />(Chy, State, IJp Code) <br />(408)316-1767 <br />STDivP (MBs Code -Telephone Number) <br />ertnitsQpge.cpn <br />(Email Address) <br />Sketch (De iled plans may be submitted) <br />a G\ <br />l <br />L1 U V <br />i <br />He'_9� CL 'i3 �.C.L 3 I�TCL voIF�IC1-- <br />fo a LJtge <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the -- side Of <br />ofjj�}„ �„�"'�rR �r,rc a P��,ur„�h ,���pproximately QQ teeUQmile by performing the following work (description of work): <br />Wo ^ w u commence on or after k-1- 3 for approxunatety rw <br />ys. <br />I, the undersigned, certifythat I am the owner of the respective property, <br />work described above in ccordance les and regulations of San Joaquin qualified <br />fCouo o and subject to isent the ns a and agree to do the <br />e9 q County ) inspection and approval. <br />---- --- ,VPP3 6-13- L-) <br />a ure of Appitcan - tie Date <br />