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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date V ! OFFICE USE ONLY <br /> TO: San Joaquin County JOB # /3052.- REF # <br /> Department of Public Works APNCR # <br /> EXP. DATE _L15 <br /> 15-O - <br /> 7 VALID• L.• -0'7 TO 1 -15-OS DRIVEWAYS <br /> —� (Applicant Name) STREET WiLGoX '0, <br /> AREA f E6S T d QUAD N� <br /> TYPE lL F4o 5a <br /> (Mailing Address) FORMS <br /> O NOTE <br /> ZOO 7 <br /> (C ty, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC`C-ONTROL PLAN <br /> SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> R'ETLRN pERmrrS TO: <br /> P"E <br /> .SOB PROCESSNG DESK® SLO .. <br /> 4040~LAM <br /> STOC , CA 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on-the_ 4F-44� JP. sides:of <br /> ' / �++/rix �, approximately 373 /fVFL,9/mile /Uakl_N <br /> of (/eafGc/k �yrv._ by performing the <br /> following work (descrip+tion of work) : Q�& �jAt/P � af�L��rJXe l��J�¢ 'L��'–,b��Z <br /> aa'-CX' ' 'ay r- .76d, <br /> �rs X,168s'T C� j� t`.oGe' i / ✓ ® S(✓C> G G /If <br /> eve' <br /> -le r6i4Z_ a 2 i✓ ST <br /> Work Will commence on or about Za72LZ 7 for approximately <br /> (% <br /> days. <br /> -I, die u_udersigned certify that I am the owner of the respective property, or am <br /> qua> ied,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 /> aspeGtion._and approval. <br /> Signature'o Applicant - Title ' Date <br /> MMTSR.PS\FEES®L (6/00) <br /> it <br /> i <br />