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7k �f <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRTN`7'- <br /> Date ��� �1 / OFFICEl USE ONLY <br /> To: San Joaquin County I'JGB a /3 REF <br /> Department of Public C 'Works LPN CY <br /> EXP_ DATE /s/� <br /> v_kLID 7 iZ T iS DRIVEWAYS <br /> (e�pplicant Name) STREET al_-5 <br /> A=- LoD/ QUAD _ <br /> L TYPE �P>TS + <br /> (Mzil__^_g 3_dd-ess) FOP.MS s5 Ltirt/, -2 <br /> NOTE �— <br /> � ' c' 7.)y <br /> (C ty, State, Zip Code) I <br /> 17..2S- -1159- 7,�/s <br /> (Area Code - Tele phone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.0-D. <br /> <PAO 309-739-5-0 <br /> 09'739► -S'0 CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> other-w-se encroach on County Highway Right-of-day on the L45T side of <br /> approfimately feet/mile E�4Si <br /> of b,, performing the <br /> following work (description of work) : <br /> t2t 2 r� A i-A css S�iC�,t�� 'S� <br /> P.S EEDE_V <br /> Work will commence on or about -7/,72,:,,P for approximately <br /> hd 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 /> /!rn-t<.E�•I r"�c*Cc•w.- - - C�•G.f. lS///t'J4 TC/� /C��///% <br /> S= uatn-a Gf 'z=caut - Title -ate <br /> MiSTE:?.PS',•e EESC-ML (6/CCI <br />