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PLEASE PRINT: <br />Date <br /> September 6, 2017 <br />To: San Joaquin County <br />Department of Public Works <br />Ground Zero Analysis, Inc. <br />(Applicant Name) <br />1172 Kansas Avenue <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />209-522-4119 <br />(Area Code - Telephone Number) <br />gza@groundzeroanalysis.com <br />(Email Address) <br />APPLICATION FOR ENCROACHMENT PERMIT <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />NOTES <br />OFFICE USE ONLY <br />1(005 REF # <br />CR # <br />11-1-17 <br />DRIVEWAYS: I 0 --ic - I 7 TO 1 [-I-I --) .i D vir ha A -FP rrY <br />QUAD 57/./( . <br />FORMS <br />Sketch (Detailed plans may be submitted) <br />See attached site map identifying well that needs to be destroyed. <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High Right-of-Way on <br />the South side of W. Durham Ferry Rd. approximately 88 fee ile east <br />of Highway 33, Tracy, CA , by performing the following work <br />ci <br /> escription of work): <br />Work will commence on or after October 15, 2017 for approximately One 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 />it( (7 <br />Signatur f pplicant - Title Date <br />Y IFORIOS A TEMPLATESENCROACHMENT PERMIT APPLICATION do* (08/09)