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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date �� ZOO OFFICE USE ONLY <br /> To: San Joaquin County JOB # X30 SZ -fo REF # <br /> Department of Public Works ADN CR" # <br /> S EXP. DATE <br /> VALID TO <br /> DRIVEWAYS. <br /> (Applicant Name) STREET 040 Avi- <br /> AREA SToc.KTO).N QUAD E.5 <br /> Q-CLQ-D 11UESl �L1.,�E. TYPE �FLLhbL� TAS <br /> (Mailing Address) FORMS ti-Z7 <br /> NOTE <br /> -��- <br /> (City, State, Zip Code) <br /> `T4Z. --t S 3 7 <br /> (Area Code - Telephone Number) , <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> f-c.rye-- Tb -'['Ct CURRENT M.U.T.C.D. <br /> 4 8 CALIFORNIA SUPPLEMENT <br /> P M 3 0 �•�-�j <br /> The undersigned hereby, applies for permission to excavate, construct and/or <br /> otherwise-encroach on County-Highway Right-of-Way on-the - �Sa- side-of - <br /> OR� _ approximately ZLQ' eet mile t,,-1c-,97r-rl <br /> of t P,-&M rCE-t� 't>*r2 444%-C*--S - -performing the <br /> following work (description of work) : cXeA­4AYt4 ' sC AI <br /> T"6' tNIf I&Jr IFL TO SLa'm.%1b S lto t SZa <br /> CV--) E¢- PLOY c 1..�d.S V=. oem <br /> bag--,&3 5%r.>Ew A•uc , T ��uttE-E-- DEV g Tel �P►�c,7 Po Q. NW. AJ <br /> z'�-N - 30 544a14S <br /> Work will 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, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> bids Q`r->6 — ' ^.j��f lel � _d -•� <br /> Sitjnatui7e of Applicant - Title �� �O! WV Z_ 93J tOOZ Date / <br /> MASTSR.PS%FUSCRDL (6/00) - - <br /> G3A1 -0t J <br />