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q <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:' <br /> Date Q'T:1 P' -U-i. OFFICE USE ONLY• <br /> To: San Joaquin.Count.y JOB # REF # <br /> Department of Public Works. APN CR # <br /> EXP.' DATE ///D 7 <br /> VALID• /a-/-07'. TO 1,41-97 DRIVEWAYS: <br /> (Applicant, Name.) STREET X111 <br /> � ` AREA QUArj <br /> TYPE <br /> (Mailing Address) FORMS. <br /> ba NOTE <br /> (City, State, .Zip Code) <br /> Uvl 64,1 Aw__l <br /> (Area Code - Telepho a Number). <br /> Sketcb, (Detailed plans inay be- submitted)- <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> C CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> . �� 3aSG(oS2► . �- • <br /> 102.4ZSOI�j�L- . <br /> The undersigned hereby.applies for permission- to.excavate, .construct and/or <br /> otherwiso-.encroach-oiti.-Ctiurstg-Tiighway Right=af-.Ka:y--ox.-the �tsca-r-uz : side::of - <br /> C r"'nz 1 �-- approxi.mately ----s 90:5, feet/Of <br /> _ UltF,�r- <br /> b'y"per€ormirig the <br /> following work (descript:ion of:work).: 11ASror I NS(N �zPL. Ch WS SS2Wic:67 <br /> �jf�4JJ�(_;7 V-:>EFQQ l2EC > <br /> Work will ,commence on or about 01 for approximately <br /> �O <br /> days. <br /> I, the undersignedcertify, that I .am the owner of, the re spective..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 /> S)u2E- <br /> `1 ►lbs 2 ��26y*v -o-7 . <br /> Si ature of Applicant - Title Date <br /> )Msv , <br /> S\P88S®L (6I.00) •' ` <br />