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JUL- 18 2014 <br /> APPLICATION FOR ENCROACHMENT PERMIT R rvT+lVED <br /> PLEASE PRINT: <br /> Date :�./I Z f OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> p VALID 0 ZZ_L¢ TO - - DRIVEWAYS: <br /> (Applicant Name) STREET L] eo�-I/ Ry <br /> AREA & QUAD <br /> 53 RZVEK PARK PLAC F F, TYPE -(- <br /> (Mailing Address) FORMS 141Z <br /> NOTES <br /> F 12 E S N O GAr 7- <br /> (City,State, Zip Code) <br /> (G59) ]SHE)- 1E)2-1B9 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> SF >= ATTAC-HED D RAWTLNfi- <br /> RFPt-AGF- PO LE <br /> PM # 31 o 7 5 0 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Ear ST side of I-F E lel 12`( R D approximately feet/mile <br /> of FAST fZ=VC K- IZ IJ., =NTFIz SEGTSCy performing the following work(description of work): <br /> RF -PI-AC T-�-r-D o t= <br /> Work will commence on or about. ' ` _ 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 with the rules and regulations of San Joaquin County and subject to inspection and approval, <br /> Y-/I 7-/I H <br /> Signature of Applicant itle Date <br /> -'/kREr-> MAbDoX (U-yl 1--) <br /> EtA • E L EG. E5,T-=/t4A-rc V <br /> M:ICEPITRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />