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N, z <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date f1j` zoo 0 OFFICE USE ONLY <br /> To: San 3vaquintetuJOB # 73BS.Z-G REF # S- 6ra.4a <br /> . a <br /> Department of P Works APN CR' # ' <br /> EXP. DATE 12-13/108x' <br /> VA4• VALID 22/DS TO /A J�140 DRIVEWAYS: <br /> (Applicant Name) STREET We4er 4ye,ue. <br /> � C AREA _i'�ct/v" QUAD42z-92 �S <br /> �sT Z/%/%� TYPE Zell D/e <br /> y, /(Mailing <br /> Address) / FORMS ,glcvu� X-29 <br /> iV• <br /> 64. Ise" V� NOTE <br /> (city, State, Zip Code) <br /> ea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> /0'V9 9 3 <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the __ side of <br /> IdA49 4 ► approximately ofee /�rtie 15KW <br /> of [-*-Jo* 5 r , by performing the <br /> following work (description' work) : <br /> �2 ll` vim. <br /> Work will commence on or about Z for approximately <br /> 90 <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 /> inspection and approval. <br /> , s s �i� Z �� _ • <br /> Signature of Applicant - Title D to <br /> MASTER.MFERSCEDL (6/00) <br />