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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date v V OFFICE USE ONLY <br /> To: San Joaquin County JOB # ✓052' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE D'j•D7 <br /> VALID G-I -d7 TO `d-/-D DRIV$QPAYS: <br /> (Applicant Name) STREET � � <br /> AREA QUAD <br /> TYPE T'Qi'USY <br /> (Mailing Address) FORMS <br /> NOTE <br /> ( ity, State, Zip Code) + s1 <br /> l —%s6 4— <br /> _ <br /> ( <br /> re a Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> /Z '" 41- �S� SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> joe ppA)cESSM K r . <br /> 4040 West LAM <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> iZee sid of <br /> other se-encroach on County o <br /> Highway Right-of-Way- n the . )l <br /> approximately Jr fee /fie -so �7 <br /> Of <br /> a �� J� by ""perthe <br /> fo}min5p <br /> following work (description of wor ) : <br /> U�C✓� Cc '� 2 rih i r �7 CSS r / p ✓ .O <br /> Work will commence on or about v' 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 /> iL <br /> Signature of Applicant - Title 'b Nr 91 Cool bate <br /> FASTSR.PS\?nSCHDL (6/00) ,-: f :";dpi ` <br /> i <br />