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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date l/✓ v OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73ds Z-Co REF # <br /> Department of Public Works APN CR" # <br /> EXP. DATE <br /> VALID &'-11-07 TO DRIVEWAYS: <br /> (Applicant Name) STREET 7-�4 A"Z AW, <br /> / AREA 5,1yGkeyAl' QUAD E5 <br /> v � 51` G—�►/. TYPE-P--.C -Hot.f 88/-4tr"L.'Ar-tj <br /> (Mailing Address) FORMS �� L✓w�, <br /> ge- <br /> NOTE <br /> (City, 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 /> F�ETlJFM1�E iTS <br /> JOS <br /> 4040 vrr.c LAW* <br /> a 1 00KWN, CA 9504 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwiseencroachon County.Highway Right-of-Way-on-the QST Z;5 7 side6of>/ <br /> approximatelyee /.m±- <br /> of by—performing the, <br /> following work (description of work) : C7 �,�✓P /' Uk`� <br /> 1,9s,r ,-e7c16 R' IV r,KT Ae, <br /> Work will commence on or about " for approximately <br /> �o <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 /> Z <br /> Signature of Applicant - dale A1W LOG Date <br /> MASTER.PS\MMSCODL (6/00) <br /> i xL 1/S f : <br />