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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 d-rQ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE %Z -/-/ <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREETor <br /> ` I i "� ,,/ AREA QUAD <br /> B5D —% �1 WOC-` LP—d , TYPE <br /> (Mailing Address) FORMS Lj <br /> NOTES <br /> +SGcL , t ClS�a� <br /> (City,State,Zip Code) <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 KAISER RD. side of E. MARIPOSA RD. approximately 2.500 feet/mile FT <br /> of by performing the following work(description of work): <br /> Work will commence on or about 10/23/2015 for approximately 1 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 /> TONY LIN-CONSUTLING FIELD ENGINEER II 4/15/2015 <br /> Signature of Applicant-Title Date <br /> M9.CENTRALSERVICESICLERICAUPUSSV.WKWASTER.PSIENCROACHNIENTPERMITAPPLICATION.DOC (09!13) <br />