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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> U <br /> Date OFFICE USE ONLY <br /> � � / <br /> JOB # 'l3oSZ-� FcEP <br /> To: San j oacniin County p pNT CR n <br /> e artmmef int of Public Works <br /> E=SP DIt-q � OCO <br /> VALID 11'I" TO _S DRIVEWAYS: <br /> (Applicant Name) STREET Wluoua Sl: <br /> AREA :51� k — -- <br /> b iaL2=.�:n . TYPE _MLL HO QUAD <br /> (Mailing P_ddress) FORMS cn4w-'o <br /> NOTE <br /> (City, 5 -ate, Zip Code) <br /> ( ea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> k;�L 3 Oct, <br /> lies for permission to excavate, c nst ct and/or <br /> The undersigned hereby app P side of <br /> oth rw se encroach on County Highway Right-of-Way on the <br /> 4 approximatel feet/renTp_ <br /> OF <br /> by per <br /> r min he <br /> _.following .work (descripti n of work): <br /> V e <br /> for approximately <br /> Work will commence on or about <br /> a 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, regulations of San Joaquin County and subject to <br /> inspection Ad approval. <br /> Date <br /> tie <br /> RETURN PERMITS TO: <br /> iM1ASTE?:.PS••,FEESG2`L �e�oo, PG&E <br /> JOB PROCESSING DESK —BLD 1 <br /> 4040 WEST LANE <br /> c- r,-%e v•rnhi r A qr;gna <br />