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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT, <br /> Date OFFICE USE ONLY <br /> TO: San Joaquin County JOB # /3�S7r�O REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE 6")- 69 <br /> VALID -) TO 1-0"7 DRIVEWAYS: <br /> (Applicant Name) STREET A16AREA ,0 -, QUAD <br /> 4-) TYPE <br /> ✓' TYPE <br /> (Mailing Address) FORMS �� <br /> NOTE <br /> Sbate, Zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> t� �`�T-". side of <br /> otherwise- en on-County Highway Right-of-Way-ori the , <br /> ��C,���'Npt��(� •:'- approximately eet - d <br /> C f C /�/a'!��n/ r'_-�V• t�J1' by per€orming the <br /> following work (description of work) - -D/C2 4V <br /> mC�f/+ � ref"' � 5 <br /> Win/ �3 <br /> Work will commence on or about '� c7'a 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 /> 17 <br /> Signature of Applicant - Title 91 :01 WV Ql ate <br /> MAST8R.PS\FEES®L (6/00) ! ,1 :;7'.l - 4• <br /> i <br />