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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date It, '07 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE i l-115,-Ing <br /> VALID• iy-�-o1 . TO \\-1S--o-7 DRIVEWAYS: <br /> (Applicant Name) STREET _/, 4611Fe AK <br /> AREA QUAD 1=S <br /> TYPE -_$EI.C. H c Le * R.�E <br /> 'o <br /> (Mailing Address) FORMS - 5�We-2-1 <br /> NOTE ° <br /> (City, State, Zip Code) <br /> � <br /> 'IAL- 1,614 <br /> (Area Code - Telepho a Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> �G CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> 3d5q 22i-I . <br /> 1624-I'l 1�4- <br /> The undersigned hereby applies for permission to.excavate, .construct and/or <br /> otherwise-encroach on CO'Lmt°g Highway Right-af-Way-on.-the CA�r-. side:of <br /> 5-wzhi R Ak2F approximately _ Ibos� feet/ - SC)U_r_LA <br /> of �= . W IJ ,VA t��rn � Mrr_ STb Ca:' epi .: by -perf orming the <br /> following work (description of work) : ►tvScp��_ �t�=u� /Z°P t_ C,zap )� <br /> Work will commence on or about l0. - 6\ -O -1 for approximatel <br /> 3o <br /> days. - y <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 /> Si ature of Applicant - Title Bate <br /> R0e� 4,Z-VoKod d1S (LIJi <br /> MASTMr.PS\nzSCODL (6/00) ' <br /> i <br /> 1\ <br />