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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /d / r200 "' OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> r (-7 VALID• :z- TO 3- D7 DRIVEWAYS: <br /> / s(Applicant <br /> Name) STREET Z�4& I" <br /> AREA -7;e <br /> QT <br /> TYPETQC-LLdo 4 APR <br /> (Mailing Address) FORMS Z7SZ u a!4 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code —Telephone Number) . <br /> Sketch (Detailed plans may be submitted) <br /> V) TRAFFIC CONTROL PLAN <br /> tr SHALL BE AS PER <br /> d�+ 0 CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> © °^ <br /> "�• C= 4 <br /> cn h+ tat <br /> O <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise encroac on-County Highway Right-of-Way-on-the .�7'` 13id .:of - <br /> otherwise <br /> L' 4Afe-S' approximated /G') 7 ' ee /mile o2T/� <br /> of z- X772 l /.��`J�' by -performing the <br /> fo.Uowing work (description of work) : <br /> O 6- ml- - <br /> 5t 71- <br /> Work will commence on or about / 2_(9C7 for approximately <br /> U <br /> days. <br /> I, the undersigned certify that I am the owner of. the re spective, 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 /> ��-Ito," -oma <br /> Signature of Applicant- Title Date <br /> MUM.PS\PSBS®L (6/00) <br /> 7"tt / �� <br />