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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date 1/o OFFICE USE 0PIT..�Y <br /> To: Sar. Joaquin County JOB ## <,p REF # <br /> Department of` Public Works APN CR # <br /> EXP. DATE <br /> V VALID. TO /O--/ C1 DRIVETRAYS <br /> (Applicant Name) STREET !n/i .✓ltlG��V ST. <br /> TG <br /> � 1�/v AREA S7KA/ QUAD �S <br /> / TYPE `t�t�(-HO - $TSE NCf{ <br /> (/Mailing Address) FORMS 5 1titN Z <br /> NOTE <br /> (City, State, Zip Code) <br /> i <br /> 5W <br /> (Area <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A� __5'0-5_,57Z-44 4 G- TRAFFIC CONTROL PLAN <br /> ✓vim �J7 ,� j SHALL 8E A.5 PER <br /> CUR2ENT M.U.T.C_D. <br /> CALIFORNIA SUPPLEMENT <br /> RETIMN PERMITS T :PWE Sly/'e. <br /> �P 76 <br /> s08 PPOWESSMVt3 DESK. BLD <br /> 4040~ L <br /> 8TOCKTON CA 95204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise- encro ch can County Highway Right-of-Way the S'c_W7� side.of <br /> Cc%-'L�✓✓ c rr r/ approximatelyJ c�, ee /-mime <br /> of /7C?� sJ�1/� Ott , �' �b by "per€ormirig the, <br /> following work (description of wprk) : �✓yU �>�� �/�`j���/Q�, ��� L� <br /> Work will commence on or about for approximately <br /> day's <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 /> A)ieJf L-ll,�IJ <br /> Signature of Applicant - Title / D to <br /> MASTSR.PS\PERS®L (6/00) - <br />