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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE P°RINT <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73495d-60 REF # <br /> Department of Public Works A.PN CR # <br /> EXP. DATE -d S <br /> VALID -7--7-CJ?) ' TO /D-iS-vg DRIVEWAYS: <br /> (Applicant Name) STRfiET Ff.&Nkck cAMP iZZ. <br /> _ __,.,,.... AREA —ySr--LL' k QUAD _ <br /> 46 � 1 � TYPE t�.u.- Ff o� <br /> (bIailiag Address) FORMS �fuhc7 <br /> _57t� a 1 17_5NOTE <br /> (Ci y, State, Zip Code) <br /> . 4 4. <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL �Af� <br /> ( b A �G� --' SHALL BE AS PER ` <br /> CURRENT M.U.T.C.D tv `- n <br /> CALIFORNIA SUPP(-r MEWT =_ <br /> az <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise encroach C ty Highway Right-of-Way-oA the t-j side of <br /> El Fapproximate],,y CC> <br /> of �``� ir_� by-performing the <br /> fowing work (descri tion of -work) : <br /> JTVAIIES U <br /> Work will commence on or about 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 /> inspet!C3i�n and approval. <br /> Signature of Applicant - Title Daae <br /> frnsrER.as\aass®;. (6/00) <br />