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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date : U OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 7✓0652-6 REF # <br /> Department of` Public Works APN CR # <br /> EXP. DATE S-0 <br /> VALID _45'- 1'19TO -lS-P DRIVEWAYS: <br /> (Applicant Name) STREET i'XL.E ox) <br /> AREA QUAD <br /> /��—�/ �=/ClD.aV <br /> 4 N� <br /> ri�� TYPE l-6 i, rxJ! <br /> (Mailing Address) FORMS <br /> <��za NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) _ <br /> i <br /> Sketch (Detailed plans may be submitted) <br /> ��� ��z���,� _ TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> ldL CURRENT M.U.T.C.b. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: <br /> joe PROCESS*4G DESK aw <br /> 4W0 W et LArle . <br /> STODISToN•CA 95204 <br /> The undersigned hereby applies for permission toexcavate, construct and/or <br /> otherwise-encroach on-Count Hi hwa Right-of-Way-OR-the f�ST.iG l °5�` sid .of <br /> y g Y. � <br /> /1?1 y Rio 14)ve approximately 46 eeeee I✓O.�T/� <br /> Of � r�•+'�" 6G�1`61,,✓: . . by-performing the <br /> following work (description of work) `6:, OA✓e bbl a L X ,V <br /> avill C� .ory ✓Ick a /ZoX• /9' iV _ A/ o o access <br /> i n t'J, o G i / CS �'V /lov%D.c r9 s S✓G• 6 /1�[.! ' GS, r7 ✓1 L <br /> 7` .✓ ✓e. ir✓ S)� AA - <br /> Work will commence on or aboutf for approximately <br /> 90 <br /> days. <br /> I, the undersigned certify 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 subje-c"t 64 <br /> inspection and approval. <br /> Siqmnature of Applicant - 13 a at..&- <br /> MSSTHR.PS\FRRS®L (6/00) - `^ <br />