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APPLICATION FOR ENCROACEMENT PERMIT <br /> PLEASE PRINT- <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73052-(a REF # <br /> Dia mme�nt of/ Public Works nPN CR # <br /> rT//� /.p EXP. DATE 1 <br /> VALID Z 1 TO Q1516 G. DRIVEWAYS <br /> (Applicant Name) STREET GiEk7YLt/D8 /;1/E_ <br /> AREA 4TbcMrbn1 QUAD L <br /> TYPE <br /> -4 <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, s a.te, Zig Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted.) <br /> The undersigned hereby applies for permission to excavate, co truct and/or <br /> otherwise encroach on C ty Highway Right-o€-Wa on the s' of <br /> approximate feet/r�� <br /> of y rforming th <br /> foJ_1aw' g w (.description-_o£ work): <br /> Work w'1 commence on or about for approximately <br /> days. <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, requlat'vons of San Joaquin County and subject to <br /> inspection and approval - <br /> ZiL <br /> r <br /> Sigaatur2 c� Arp icant - Lytle ate <br /> MASTEIA?S%FEESC4WL {9,001 RETURN PERMITS TO: <br /> PG&E <br /> JOB PROCESSING DESK -BLD 9 <br /> 4040 WEST LANE <br />