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• � , c�r�n� 308'7385$ <br /> APPLICATION FOR ENCROAC124ENT PERMIT <br /> PLEASE PRINT: <br /> Date I" _ (+ _ OFFICM USE OATLY <br /> TO: Sa.n Joantin Cowity JOH a l O s REF 4 <br /> Department of Public Works zPN CR" # <br /> C`;oi \ <br /> EXP. DATE 3 lS )Z <br /> DajJ I� ra � ,.;Ecc L 4� -Ie-ch 1 VALID I i�L To 3 IS Z DRIVEWAYS: <br /> (Applicant Name) STREET566&66cdl0 <br /> Q �Q t p/ ➢n,, AREA fit '�SQl1XLQUAD _41a) <br /> 0 u &� - par(, pixj�A17� TYPE '$7 �ELGNOILE$ <br /> (Mai?i^_g Address) FORMS <br /> rIO NOTE <br /> • 'q3 <br /> (City, State,, Zip Code) <br /> (Area Code - Telephone Ntnaber) <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 /> I <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the '�rS�S�' + �S+ side f <br /> Lx_JCc AcG:GrftecLif.0 . ?,,A. approximately aZ�(oL(c� feet/mile <br /> of 4,1norl h.j dRA i G by performing the <br /> following work (description of work) : �L au�v�a i��[�` G& piw'`ic 'Mai A <br /> •�i-[� �'-Chi`', T"eS i�i 1�'i�� �GYYI� . . <br /> Work will commence on or about A 131'L for approximately <br /> 30 <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 rul(=s, regulations of San Joaquin .County and .subject to <br /> inspection and approval. <br /> S= e of = t - T :ate <br /> NFSTc.PS'%FEESC3a!, !F/CO) <br />