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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date I 1-7- B H <br />To: San Joaquin County <br />Department of Public Works <br />se1�:A1GG (C N 2IS p6?-?-Y� <br />(Applicant Name) <br />y 53,4o 5p-/sA E'-. <br />(Mailing Address) <br />&l lelemoje6l CA Qq650 <br />(City, State, Zip Code) <br />as) 783e e-1$-77 <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) SE 6- A Ci46'D <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the Alogr)4 side of N. w / c.SotJ LI,ay approximately 'V5 ;4-e ile 6,457- <br />of <br />•4sTof r- . STc-►od2.1 ST". , :STocYmo,*-) _, by performing the following work (description of work): <br />Bo2C- FP -o)" a:O e tiir 'Por_& o,.) S.STPWAcr ST % 2353 <br />iU r cJt�S�n� <br />WY. f NSr)4 Lt J-.7" CoNt,`t r ► f:69 C+ IV 664 J<-6- <br />3-10-14 <br />E4y1<-6- <br />3-/0-/4 <br />Work will commence on or about e-7-2*'.t* for approximately /10 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 with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />-:27,exp-r60oRJ>1Av47-02 <br />gnature of Applicant - Title <br />M:ICENTRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACNMENTPERM[TAPPLICATION.000 (09/13) <br />1 -17 -IV <br />Date <br />OFFICE USE ONLY <br />JOB # <br />/%G>j <br />REF # <br />APN <br />EXP. DAT <br />C13 ff/ <br />I <br />VALII? <br />0 <br />DRIVEWAYS: <br />STREET <br />s4�4ov AW <br />AREA <br />TYPE <br />/t/ QUAD <br />HSS <br />/1,5 <br />FORMS <br />NOTES <br />ll <br />Sketch (Detailed plans may be submitted) SE 6- A Ci46'D <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the Alogr)4 side of N. w / c.SotJ LI,ay approximately 'V5 ;4-e ile 6,457- <br />of <br />•4sTof r- . STc-►od2.1 ST". , :STocYmo,*-) _, by performing the following work (description of work): <br />Bo2C- FP -o)" a:O e tiir 'Por_& o,.) S.STPWAcr ST % 2353 <br />iU r cJt�S�n� <br />WY. f NSr)4 Lt J-.7" CoNt,`t r ► f:69 C+ IV 664 J<-6- <br />3-10-14 <br />E4y1<-6- <br />3-/0-/4 <br />Work will commence on or about e-7-2*'.t* for approximately /10 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 with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />-:27,exp-r60oRJ>1Av47-02 <br />gnature of Applicant - Title <br />M:ICENTRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACNMENTPERM[TAPPLICATION.000 (09/13) <br />1 -17 -IV <br />Date <br />