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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2, <br /> PG&E VALID p J 20/110 DRIVEWAYS: <br /> (Applicant Name) STREET1'Amea <br /> AREA 59z"v QUAD 4 <br /> 850 Stillwater Drive TYPE c 4!:�>AYAWarc <br /> (Mailing Address) FORMS SylvUl <br /> NOTES <br /> West 1;ac:r2mentn, C.A 95505 <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 Highw Right-of-Way on <br /> the West side of S Walker I N approximately fee ut <br /> ile Soh <br /> of East Main St , Garden Acres , by performing the following work( escription of work): <br /> _Re lar.ing service cable alnnn withnn le rPplacemPnt of ri yatn ornpprt� <br /> Work will commence on or about_ � 1 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 /> Signature of Applicant-Title Date <br /> E.,PUS 5VWKWASTER.P&ENCROACHdENTPERMIT APPIICATICUDOC {01'081 <br />