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APPLICATION FOR ENCROACER4ENT PERMIT <br /> PLEASE PRINT• <br /> Date l�d� <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB #. 73-005-Z-(�2 REF # <br /> Department of Public Works APN <br /> CR" # <br /> /, �• <br /> EXP. D TE Z t S•o` <br /> VALID 2 TO 2-15- 05 DRIVEWAYS: <br /> (Applicant Name) STREET N\GQ Kn fcJa <br /> fi01 n/ AREA 4fh�L+ ./QUAD <br /> TYPE 6 <br /> (Mailing Address) FORMS ,Gly <br /> �f ✓V. G�+ �3Z�t� NOTE <br /> (ci y, State, Zip code) <br /> (Area Code - Telephone Number) <br /> sketch (Detailed plans may be submitted) <br /> $G TRAFFIC CONTROL PLAN <br /> rj G� SHALL BE AS PER <br /> CURRENT M.U.TC.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County highway Right-of-Way on-te <br /> s/.;&6, s ,r1L/t h ✓DIPT�. side.of <br /> of S�'.ql� Urr7 VKaPProximately ' fee )mj-jre <br /> following work (description of�work) ,,/� t hyer€off the <br /> ✓l Q oKG vS�, lU <br /> u CK ,t T c `�✓ d f d <br /> Work will commence on or about D d <br /> Z<5? days. r for approximately <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 sub <br /> inspection and approval. ject to <br /> Ss.gnature >of Applicant - Title <br /> g°�efzr Z_ J g'- bate <br /> MASTBR.PS\FR3SCHDL (6/00) <br /> i <br />