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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date ��`T/I� <br /> OE'FICS USE ONLY <br /> To: San Joaquin County JOB #_73US 2-" REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE _6-15--o-7 <br /> (-J VALID a- D-O7T0 -/S-D 7 DRIvEwAYS: <br /> (Applicant Name) STREET f'}�W <br /> "�r (��t d (�(��S Zs�,� AREA QUAD <br /> TYPE �� o C !2/)c, <br /> (Mailing Address) FORMS SS bo <br /> NOTE <br /> /`-��'✓• � Chi. i 5 �C� `-f� <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> J o� SHALL BE AS PER <br /> /'✓�' /c� �-3`��� CURRENT M.U.T.C.D" <br /> CALIFORNIA SUPPLEMENT <br /> RETtM PERWS TO: <br /> PGM <br /> MOB PP40MSSM O - OLD I <br /> 4040 HVrst L.it1� <br /> BtTL MC tC II 1 XA 952W <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way 031-the side.of <br /> approximatel <br /> of ii/✓CL,�j Q Ur l- ✓, 1 . . <br /> by "performing she <br /> followingwork (des rip"tion of work) : �tiE / v/e a� (�-,,(, <br /> I 5s ,5 ciG'c G f 7,. t/ Iry <br /> S r r. cam' 7D 5 S, S 7c/moi �r'r/ <br /> Work will commence on or about 307 for approximately <br /> CJ <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 of Applicant - Title ` HLU <br /> { :d' WV � { Dat® <br /> MASTER.PS\FRGS®L (6/00) <br /> rf <br />