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APPLICATION FOR ENCROACEMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> ✓ OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 7305Z— Co REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> vz VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET F:L -P0941>0 <br /> AREA ecu QUAD be <br /> TYPE '� -f�tioLb TRa mat <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 4Z- /s c/D <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> RETUM PERMIrM TO: CALIFORNIA SUPPLEMENT <br /> PGAE <br /> Joe PRWESOM DESK- BLD 1 <br /> 4w vwst t.arw oS1 XTON, CA 95204 <br /> ff <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise- encroach on-County-Highway Right-of-Way oa-the 4,_C45=1 side:of <br /> 5, �FL S-77 approximately SCo 2' ee / 3:z Vc,,' ?TIil <br /> of "JS- /�/YAP by "performing the <br /> following work (description of, work) : <br /> M,,/ <br /> �c ,v ,e �gs ZX,061L 7?7P <br /> 5 <br /> Work will commence on oi- about 2 6o for approximately <br /> days <br /> I, the undersigned certify that I am the owner of the re spective, 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 and approval. <br /> r—t z req <br /> 'A?0P, -Pflr- d3C <br /> x`16 <br /> Signature of Applica=nt Title CO :Q' WV s- NVr ZOOZ Date <br /> MASTER.PS\FS8S®L (6/00) <br /> (5 A130 <br />