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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT. <br />Date K— 47 <br />- OFFICE USE ONLY <br />JOB s 730052 REF e <br />APN CR 8 <br />To. San Joaquin County <br />Department of Public Works <br />0(-e <br />EXP.DATE <br />VALID 70 snizoza DRIVEWAYS: <br />STREET Vine St. <br />(Applicant Name) <br />AREA Escalon QUAD ' <br />TYPE Pole Replacement <br />FORMS SSANVV <br />NOTES Special Conditions <br />(Mailift Addresil <br />��il• `JL -I�,; <br />(Cityi,'State, Zip Code) <br />yLk- 3)1,- l 710! <br />(Area Code - T epbrone Number <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />V, <br />I <br />4 � c L <br />a' <br />X gSL <br />T ?L <br />f <br />IIILLL <br />The undersi d hereby applies forPqeermission to excavate, construct andlor otherwise encroach on County Highway Right -of -Way on <br />the side Qj rli ST approximatety 2 tulle A/ <br />i <br />of Srifn f +� GS�< v. by performing the following work ascription at work): <br />✓r0 Z Vile <br />to ocr, <br />Work will commence on or after for approximately. days <br />1, 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 accordan th the rules and regulations of San Joaquin County and subject to inspection and approval. <br />Z- j'•ZLI <br />S Appllant • Title Date <br />ww,.mw,c+eaiue.ea.c+.r Am <br />