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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date T�. �-�-� �� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 r 90.5'2- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ((- 1 ' 15 <br /> Esteban Ruiz VALID_ �(�-/S' TO 17 �/ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> I�^-y C� �t ARON QUAD <br /> �j � <br /> (Mailing Address) FORMS W Itl 2 <br /> NOTES <br /> (City,State,Zip Code) <br /> (925)327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the east side of S Escalon Bellota Rd approximately 3680 feet/mile south <br /> of Copperopolis Rd by performing the following work(description of work): <br /> Replacing a deteriorated utility pole <br /> PM 31119252 <br /> Notif: 109590429 <br /> Work will commence on or about C �LA' for approximately days. <br /> (0)�-3 i l5 <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 /> Signature of Applicant-Title Date <br /> M'J„ENTRALSERVICES.CLERICAL1PUB-SV.WICMASTERFSENCROACHMEPoTPERMITAPPL.ICATION.DOC 103V131 <br />