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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> I p� <br /> Date ��2/c)< p OFFICE USE ONLY <br /> ' �yy / <br /> To: San Joaquin County JOB # 7-505 -�O REF # <br /> Department of Public Works APN CR # <br /> EXP. ,DATE� r�P <br /> VALID 1' TO IS B(o DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA LoDI QUAD IV15 <br /> TYPE Z6%AW46� 1064W 4 YX664W <br /> (Mailing Address) FORMS _Ss_�� .�Z9 <br /> (dCO; , •5 ` 6 NOTE- <br /> (City, State, <br /> OTE(City,, State, Zip Code) <br /> e I&2-1 <br /> (AreA Code - Telephone Number) <br /> or <br /> ret cl (I;etailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> t.0 cn <br /> 10' CURRENT M.U.T.C.D. <br /> +— CALIFORNIA SUPPLEMENT <br /> c.) <br /> �a <br /> Q <br /> i o 2 Zo 0 <br /> The undersigned hereby applies for permission to excavate, jonstruct and/or <br /> othrwise encroach on County Highway Right-of-Wa on the side of <br /> approximately feet/nT� h'C?1,� <br /> of by performing the <br /> AA <br /> following iti <br /> w (description of work) : <br /> -00O <br /> Work will commence on or about for approximately <br /> lnQ 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 /> JVQ <br /> i bf 6ItYoO r to �Z/oma <br /> Si ature of Applicant - Title ate <br /> RETLMN PERMITS TO: <br /> i9F.ST P FEESCHDL (6/00) QP��&��C <br /> CE <br /> JOf3 PROSS'"' DESK- BLD 1 <br /> Q 4040~ WR <br /> S CK,ONS CA 95204 <br />