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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT- <br />Date�� b{ <br />_ <br />OFFICE USE ONLY <br />To: San Joaquin County <br />JOB t 730052 REF K <br />Department of Public Works <br />APN CR N <br />DATE <br />DRIVEWAYS: <br />VALID sttrzoza TO 9ttrz024 <br />VALID <br />STREET John st <br />(Applicant Name) <br />AREA Stockton QUAD <br />TYPE Pole Replacement <br />FORMS ssn <br />(Maili g Addre sl <br />S <br />NOTES Special Conditions <br />(City, State, Zip Code) <br />4A)� - 3/G -1 7l <br />7 <br />hon N r) <br />(Area Code-Telep/r <br />S i 1 J/y �-I��� G i. <br />C <br />(Email Address) <br />Sketch (Detailed pla may be submitted) <br />7�A <br />The undersi hereby applies fol pegnission to excavate, construct and/or otherwise encroachqn ?unty Highway Right -0f -Way qn <br />5— G✓ <br />the�— side of C.Al <br />approximately W $ mile <br />of / r 1 i ETA✓+ S <br />by performing the folbwing work(description of work): <br />1 ✓; r e h <br />oC<+t�� <br />Work will commence on or after -1 -7-q <br />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 accordance as a regulations of San Joaquin County and subject to Inspection and approval. <br />Sf n plicant-Title <br />Date <br />r'idas � IUAA't cousetNlM %T1Y' KRrwI� tsm <br />1ulm <br />N <br />