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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ..,,p ���L.. - OFFICE USE ONLY <br /> To: San Joaquin County JOB # J13 �o���' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> ® VALID'.US TO DRIVEWAYS <br /> (Applicant Name) STREET A <br /> AREA G&W QUAD <br /> L r TYPE ' G O <br /> (Mailing Address) FORMSIG�u', �'2 <br /> 64, !7�5zn4- NOTE <br /> (City, State/, �-Zip Code) <br /> 1 4— <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) ],rt <br /> TRAFFIC CONTROL f�ANES =" <br /> r SHALL BE AS PER <br /> CURRENTM.U.T.C.D" CS <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach o County Highway Right-of-W ons t o _____��*�-'� side of <br /> of e <br /> approxi tely feet/ <br /> by -pe'rforming the <br /> fo „low' g work (descri ion of w� <br /> n - <br /> Work ll commence on or about L4C.. for approximately <br /> 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 /> insy)eeti�n and approval. <br /> Signature of Applicant - Title " Date <br /> MASTER.MFEES®L (6/00) <br />