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APPLICATION FOR ENCROACHMENT PERMIT <br /> .EASE-PRINT:[�7 ] <br /> a`e / Z SrOFFICE USE ONLY <br /> I San Joaquin County JOB# 7 F� QQ �j Z REF <br /> Department of Public Works <br /> APN CR <br /> -_- EXP. DATE <br /> �fi 3�-` VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET, p — <br /> J� AREA 1.a �e QUAD -- t <br /> TYPE' 0 <br /> (Mailing Address) FORMS <br /> �1 c� NOTES <br /> (City, State,"Zip Code) m <br /> (Area Code-Telephone Number) <br /> tch(Detailed plans may be submitted) <br /> ( see fk c <br /> PM# 31104282 <br /> I21.ZZ;�k3 <br /> gay <br /> One <br /> E. 02C-HAZD <br /> idersigned hereby applies for permission to excavate,construct and/or otheRvise encroach on County Highw Right-of-Wa on <br /> Lsi side of—L� �,'� l?,� <br /> approximately Zc�© ' ee mile rSa <br /> by performing the following work(,escription of work): <br /> a { l and install new Pole in line with ali nment of <br /> �cl pole li eon E.LOrch rd Road.about 413'east of Dustin Road <br /> s'Tr f 3 Z 1 S _31 a�4�S2 <br /> ill commence on or about 3/Z <br /> —�/!5 for approximately. days; <br /> —� <br /> idersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> rrG-d <br /> see 'abs in accordance w�ffie rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Sr Ei . ; ;��C,h <br /> Signa u-- of Applicant-Title ' Date— <br /> %5 <br /> ate <br /> s1ERPS2uchCdt?J%1rrn PWAII RPPLICAI LIN CUC 10+;75) <br />