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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' 'ZOC>J OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7365vREF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> �--� % - VALID '15'07 TO 7.1­01 DRIVEWAYS:. <br /> (Applicant Name) STREET DUvE ST. <br /> AREA -9!roa.�b►j QUAD 5S <br /> wE s'y TYPE_i-Q _ NoLE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City; State, <br /> Zip Code) <br /> z015( - q AC z-- [ G'5 I <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.: <br /> JOB PROMSSNG DESK BLD <br /> ; TON, Cil!9504 . <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County-Highway Right-of-Way on-the G_N. 2i' side.of <br /> (IL I V6 'mo i �r approximately --I'�A A- eet /mile Ill �i <br /> of -N - lid - S�, U GIG Mir J by "performing the <br /> following work (description of, work) : 1 ;A�IL� 1 ��Z" '� �T��•> <br /> se?_y i Cz <br /> Work will commence on or about lL1IAV,�J for approximately <br /> 21 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 /> Si nature of Applicant - Title R :01 WV ! _ NAr L007 Date <br /> MASTER.PS\FEESCEDL (6/00) <br /> $ int fy <br /> i p..d � <br /> I� <br />