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FSR ENCFLObCETm PERMIT <br /> PLEP_SE PRINT: <br /> Date B '1 d "a� OFFICE USE ONLY <br /> To : San Joaquin County JOB # REF # <br /> Department of E>ublic Works APN CR # <br /> EXP. DATE )Z-I•a7 <br /> _ VALID -ZO-07 TO i2-1-0-7 DRIVEWAYS: <br /> (Applicant Name) STREET 'SAV5ER- 1Zb. K <br /> AREA QUAD NE <br /> !D ND L)E s T L I?,VL TYPE 'P!a-L.Note l -rft&xk <br /> (mailing Address) FORMS Zb/&9,Y. JC'rf <br /> 'NOTE <br /> S TOG K TDit/, G/4 <br /> (City, State, Zip Code) <br /> fi7W: <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 /> a <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> ot4erwise-encroach'on CoL2-*1ty-Highway Right-o=-Way on the /l/DRTW side2 o7f- <br /> 124KE1?- A6. approximately feet/ <br /> of gRa1-1z1us 9L.t. /e � , LiA 44AI by perfonna.ng the <br /> following work (description of. work) : <br /> EX,,fAL 4 rE y '% 5/' t3ELL 1-101-E QLh 2 LA S /Y141A1 /4AJZy 7-K,202,1 <br /> Fr sL/ 7v P,2aPE2r7' LIAIZ <br /> 7 <br /> Work will commence on or about for approximately <br /> W days. <br /> I, the undersigned certif=y 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 /> gn3tllre or kpplicant - Title Date <br /> I'ti1STfiR.PS\ili��C�:�� if/CG) <br />