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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> To : San Joaquin County JOB # 73052'(0REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE !./-07 <br /> VALID. -/S-a7 TO S-/-07 DRIVEWAYS <br /> (Applicant Name) STREET PD <br /> AREA QUAD <br /> TYPE �c. r-FoLE <br /> (Mailing Address) FORMS <br /> NOTE --------- <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> do'�2Z�5Co <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherw's ._encr = on Count Highway Ri ht-of-Way-on-the = We Of <br /> y.. g Y. g <br /> approximatel �� CJ'D_ feet/e3 <br /> of <br /> y -performiAg the <br /> In I <br /> following work (description of: work) : <br /> Grondua 40 OWL �tlnm-­ , <br /> ID <br /> Work will commence on or about for approximately <br /> 162 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 /> i . <br /> Si mature of Applicant - Title Daae <br /> . MAS .PS\FESS®L (6/00) 1 <br /> II <br /> i <br />