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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/21/15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1(")005" REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 5 }3 <br /> Linden-Peters Fire District VALID �" �i TO -i r 3 DRIVEWAYS: <br /> (Applicant Name) STREET -VuW_1q r.l 122). ` <br /> AREA jj t a DF PJ QUAD &I F_ <br /> 17725 E. Hwy 26 TYPE zcx:�;r"TA2iye <br /> (Mailing Address) FORMS i <br /> NOTES <br /> Linden, CA 95236 <br /> (City,State,Zip Code) <br /> (209) 887-3710 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies forpermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the N/S/E/w sideof Highway 26 approximately Duncan Rd. feel/mile <br /> of _,by performing the following work(description of work): <br /> Collecting donations to benefit the Firefighters Burn Institute. <br /> Firefighters will be collecting donations from the shoulder of Hwy 26 and <br /> Duncan Rd. at a four water stop i n rsectiori. <br /> Work will commence on or about May 9th, 2015 _for approximately one 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 a ave in acc nc with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> l�— 4/21115 <br /> Signature of Applicant-T tie Date <br /> EIPVMVIV'&WASTERn&iCR0ACHVDTIPMI AYFUCAMItDOC VIM) <br />