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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C� OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73�SZ. REF'' # <br /> Department of Public Works APN CR #_ <br /> ,! EXP. DAT <br /> > VL • VALID 1012-216-7 TO 11-1-0-) DRIVEWAYS <br /> (Applicant. Name) STREET S-�-to7! �D. <br /> ,/ AREA Lock_*ft9a QUAD _Al!F <br /> (,�/Q$ ' C.., /• TYPE -f -LL/Ra_?E. ;2r- t?9e_-J-)-_tl <br /> (Mailing Address) FORMS <br /> NOTE <br /> (Cit , State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETLMN RERmn S TO: <br /> PGU <br /> See <br /> "XXESSM ASK BLD I <br /> 404oWOW LWW <br /> acs, CA 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwiseej?cr ach on Cour_ty Eighway Right-of-Wa -on-the L11f/S`T side.of <br /> /�• �/J /2G approximately f� ee /mile �sjr <br /> of ,-/-GICG o ev , by "performing the <br /> f llowing work (description of//work) <br /> �VX %ti Lei L!l � ' � <br /> 04ere <br /> rax• �� /7✓ a�SS S O+N_�J�l t� +2 �� <br /> CC 25 ,� �Gi (i "eS G1r1i1� ��ii ,p5 �/G• p '%3Ci,�/ `SFR <br /> ZoS8 Z /y, i"a Fes_ ;A1 <br /> Work will commence on or about 91Z? U 7 for approximately <br /> ADD <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 /> -711 <br /> 00 <br /> Signature of Applicant - Title <br /> MASTER.PS\FEES®L (6/00) <br />