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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7305 ` REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Lp-.1-C)l <br /> C�d VALID 4-2?-o'7 TO 9-1-o7 DRIVEWAYS <br /> (Applicant Name) STREET r L <br /> / AREA ST1C rJ QUAD CC- <br /> (� '�� TYPE �ll 4�1e. Tte,nc� <br /> (Mailing Address) FORMS ; 2-23 <br /> �tAtate, <br /> NOTE <br /> Zip Code) <br /> Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> --,4iz 44ci J" SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RE VRM PERMITS TO: <br /> Pau <br /> JOB PROCESSM DESK- BLD 1 <br /> 1040~LNW <br /> S?00CM, CA 95204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> of rwis�e-encrpacYi o County Highway Right-of-Way-ox-the 5� % side.of <br /> approximately 3l ee /mi-iG <br /> ofy,��✓0%0`� ��/. ` /Y byperforming the <br /> following work, (description of work) : <br /> C, t� <br /> /IGA VX n � � �� o� i it/ _,4 0 ~ ��-' �'K7,; c> <br /> Work wil_l commence on or about / for approximately <br /> -�!= <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 /> Signature' Applicant - Title 9� :6 WV LOBI ate <br /> MASTER.PS\PBSSCHDL (6/00) �...�L�`<77 <br /> �..�.:3 A�,dfd_i <br />