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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 8/20/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# P(U)e S hp 5 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 0--1-701`'( <br /> Robert Fauvor VALID -20 TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA , QUAD <br /> 130 Terrace View Circle TYPE <br /> (Mailing Address) FORMS 5S.k)LJ t2 <br /> NOTES <br /> Jackson, CA 95642 <br /> (City,State,Zip Code) <br /> 209-810-3413 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attached Grading Plan <br /> 1r a <br /> d <br /> 1 <br /> ` i .!s;j :,C "C.` �,G "W � f !✓ft` r'' j� r.*� ff� "(.�i�i LG. y <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the west side of Tully Road approximately 150 feeVMW south <br /> of Hammond Street , Lockeford ,by performing the following work(description of work): <br /> Remove and replace an existing catch basin and patch the existing AC walkway. <br /> Work will commence on or about for approximately one 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 /> ; "Y �- <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUBSV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />