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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> /Date (J OFFICE USE ONLY <br /> �— <br /> TO: San Joaquin County JOB # JG-(10. REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 11-1-67 <br /> VALID TO 14-l-,07 DRIVEWAYS: <br /> (Applicant Name) STREET i-y195,'� 512W Sr <br /> AREA 57'a QUAD 65 <br /> TYPE <br /> //(Mailing Address) FORMS <br /> NOTE <br /> '(City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plan-smay be submitted) TRAFFIC CONTROL PLAN <br /> 30-5,'3007 SHALL BE AS PER <br /> /v - /�Z,3,y,� f01 CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETI IM PERMITS TO: <br /> PGWW <br /> s A � <br /> Jog PROCE88M DESK BLD 1 <br /> 4040 Mll"LAM <br /> WTW, CA 9M4 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise nc oach on County Highway Right-of-Way-or�.9he�%�7w sidejof <br /> approximately 4 - <br /> of �.�1'C9r/✓/�L. Kn/P by "performixtg the <br /> following work (description of work) : r A✓0 / v vx <br /> r i <br /> „�,� �-e ti ch G. vk'. 4 11V oi If-)- e Cci'•E'. 2 4 <br /> ! ' tJx1✓C �CrJC <br /> af - 2 , i✓ �slf' o e'creSS PX• /" ,"PS �.�' v+/1GY�✓ <br /> Work will commence on or about 2'c? U7 for approximately <br /> !D <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 /> Signature of Applicant - Title 7 Date <br /> MMT%R.PS\n9SCE1DL (6/00) <br /> u _ <br />