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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -61111,) 7OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN —� CR # <br /> EXP. DATE <br /> VALID -1-01 TO _I&I -_-07 DRIVEWAYS: <br /> (Applicant Name) STREET 7L rL /4 <br /> 5,q A1 <br /> 4y 4 4j /�,5�ZA'l AREA —"The-k-76A�)QUAD _ <br /> TYPET2- ���lvtF ,4�4- _ <br /> (Mailing Address) FORMS <br /> NOTE <br /> City, State, Zip Code) <br /> (zd 9) ?vz --/4)"�_ <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) T _� <br /> TRAFFIC CONTROL PLAN <br /> 4 � 1d Z3Z8(p4� SHALL BE AS PER <br /> CURRENT M.U.T.C.D. -- <br /> CALIFORNIA SUPPL�VENT <br /> RETURN PERMITS TCS: <br /> .JOB PSE e_ cS3C fil Ci� '000i T,4 0 �? <br /> PROCESW4G DESK- �3LD � o <br /> 4040 WW Lance <br /> STOCKTM, CA 9 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwis-eTe�}croach on County Highway Right-of-Way on-the ,bsT <br /> sid <br /> /Sp JUi/� approximately y --�'� Evers% nl of <br /> of ,q 0�� ,c?I/�-, fee /mile T7�/ <br /> by Perf rm ng the <br /> following work (description of work) : 2/ L OX, <br /> 47—10 rd v,; <br /> Work will commence on or about Z p <br /> p� days. for approximately <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 /> 0 <br /> Signature of Applicant - Title <br /> ate <br /> MASTER.PS\FESS®L <br />