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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To. San Joaquin County <br />Departient of PublicWorks <br />PLC <br />(Applicant Name) \\ <br />(Mallin ddress) <br />((;ity, State, Zip code) <br />Z� Z -4Z �� 53 <br />(Area Code - Telephone Num lr) <br />5-I D iy Pfd i)..,•,.,..:1 xe • c.o. <br />(Email Address) <br />J013# <br />OFFICE USE ONLY <br />730052 REF# <br />AP14 <br />CR # <br />EXP. DATE <br />VALID <br />STREET <br />TO <br />°- <br />107DRIVEWAYS: <br />AREA <br />TYPE <br />Lodi QUAD <br />Pole Repair <br />NW ' <br />' <br />FORMS <br />NOTES <br />SSA WV <br />Spec al Cond tons <br />n <br />Sketch (Detailed plans may be submitted) <br />/N. Co'Nhz fit aD <br />C <br />CL <br />Gla q <br />The undersigLred hereby applies for ge missiyn tp excavategcogstruct and/or othervrise encroach on County Highway Right -of -Way on <br />the ��side of G✓ Ge 4' , 0'� J —approximately -7 l%�Umile � <br />of N \ 4 "b t ,o by performing the following work (description of work): <br />Work will commence on or after 0 - for appmximately days. <br />I, the undersigned, certify that I am th w respective property, or am qualified to represent the owner and agree to do the <br />work described above in accor9afCe w es and regulations of San Joaquin County and subject to inspection and approval. <br />U -s I It <br />Date <br />