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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASEPRNT: Q <br />00 IA3�23 <br />To: Sal Joegtdn County <br />OqW%Tment of Pbk Woda <br />(App1aIR Name) <br />221"zly EneA.,, 1"4 <br />WAM% m.n I <br />c'-0 49-e(� <br />(CRY, M" zip Cade) <br />Zo`1 2-42- ra 51 <br />(Ane Code - Telephone NumW <br />S"TAit/�fP, <br />(EmeYAddrep} � <br />JOB • <br />OFMF1 USEONLY <br />730052 REF e <br />NN <br />E%P.DATE <br />VALID - <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />CRR <br />10/l/2023T0 4/1/2024 DRIVEWAYS: <br />ivy ver Rd. ' <br />Escalon QUAD SE ' <br />Aerial Work <br />SSMnN <br />S ecial Condition <br />Skakfl plans may besubmined) <br />— — _ (vL <br />J 1 <br />i X Y�ie, <br />r>yaa' CL <br />�� <br />h r Rlut✓ <br />The hereby applies for to e>aavate,nstW andlor otherwise a oo Can), Highway Right -of -Way m <br />the / sided ✓ �1 appmnmatety ''y w mile t <br />by performing the foflovnlg work (descnpom of work)' <br />352`1 (050 5 <br />Work will co miens on or after /Q - I – Z- ror appro)dmately days. <br />1, the urdemgM, oar* that I am respective property, or am qualified to represent the owner and agme to do Ue <br />worabove n k desrnbed aboWith sand regulations of San Joaquin County and sugcct to inspection and eppoveL <br />i5ipneture <br />Date <br />of Ap . TWO . <br />