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APPLICATION FOR nTCROAC0ME'_ST'T' PERMIT <br /> PLEASE PRINT: <br /> Date 'Ll- 23- Q 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7.3OSZ 57 REF # <br /> Department of Public Works APN CR # <br /> "t'f EXP. DATE .�O <br /> VALID -14-+0TO • DRIVEWAYS: <br /> (Applicant Name) STREET 4J4fbi27- " Z <br /> AREA 'TBG&"A/ QUAD - <br /> TYPE ^tom NAGE �D1RE <br /> (Mailing Address) FORMS ��L✓;�ZS <br /> r TE <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 /> The undersigned hereby applies for permission to .excavate, .construct and/or <br /> otherwise- encroach on County-Highway Right-of-Way on the GJE.ST side_of <br /> /9/R/aDQT- GJ`� approximately Z'a6 feet/minisa AIDRT1-1 <br /> of LIAIL)13ERL H Sr' STGL"/CTOA by per€orming the <br /> following work (description of, work) : <br /> CA Gryy✓gTE L3EL4 /1O46� Oufle 4,124 mpi•V ^A/L BDAe6' S 714 <br /> 1A1_5'7 1LL A&_:7 ..7 AA-5 SEZ014-6 <br /> Work will commence on or about S' .ZO -07 for approximately <br /> 90 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 /> LID <br /> afore of Applicant 'title 62 :1 Wd I Z ,kVW LOOT Date <br /> MASTER.PS\FSESCfIDL (6/00) <br />