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APPLICATION FOR. ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date <br /> OFFICE USE ONLY <br /> TO : San Joaquin County JOB # 730!52-G REF # <br /> Department of Public Works APN _ CR # <br /> // EXP. DATE <br /> VALID 7 lo?' TO r/S-a7 DRIVEWAYS: <br /> (Applicant Name) STREET n�GUi / <br /> TYPE QUAD <br /> (Mailing Address) FORMS 29 <br /> NOTE <br /> (Cit , State, Zip Code) <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 /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: SC � ���� ����4 <br /> joe P(3deE <br /> PROCESSING DESK r BLD I <br /> 4040 Wisst Lams <br /> STOCKTON, CA 95204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroh on County Highway Right-of-Way-"on-the F•57 . nide..of <br /> SKJ�✓6u�N G'✓ approximate) _� ee /�ni�e i(/o � <br /> of by-performing the <br /> following work (description of work) g_l a. � /V <br /> A / T �X, J J <br /> rnal / .JP� O C <br /> of <br /> Work will commence on or about d 7 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 /> �a✓�-c� Gi�Q� <br /> I07 <br /> Sig—nature ;f Applicant - Title 90 :II WV C i �1d Ott�l Date <br /> MA-STER.PS\FS3S=)L (6/00) - <br /> t,13 <br />