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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10 ' 04 Qep OFFICE USE ONLY <br /> To: San Joaquin County JOB # / ^7 REF # <br /> Department of Public Works APN CR # <br /> EXP_ DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET JZ' ST. <br /> x61 AREA Jrccxroi.1 QUAD <S <br /> „ � TYPE $rcll.Fbi.ry XoLLE * <br /> �{ (Mailing Address) FORMS S;�;&64 'e-zy <br /> NOTE <br /> 0 <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLA81 <br /> SHALL BE AS PER n aCON <br /> T <br /> =� CURRENT M.U.T.C.D. 7-4 ca <br /> i CALIFORNIA SUPPLEM*IT C-4 <br /> c ut crn <br /> r rn <br /> _ <br /> cc)� <br /> l !o � X020 Co7Lj. 2 N �' <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherenc oach on County Highway Right-of-Way on the ide of <br /> approximatel feet/==In <br /> of by performing the <br /> following ork (desc ipt'on of work) : P ;9 A-r-i. i <br /> Zfl <br /> QP.oa <br /> 06b 11 <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 /> inspection and approval. <br /> r\\F7EESC1H.DT1, <br /> f Applicant —Title Da e <br /> MUM(G/GG) JM r !'ERMffS Tom• <br /> PGWW <br /> _�'S,*&4G DESK- BW 1 <br /> 4040 V%W Lw* <br /> STOCKTM. CA <br />