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APPLICATION FOR ENCROACBIAL PSRMIT <br /> PLEASE PRINT <br /> Date X' hq OFFICE II88 ONLY <br /> To: San Joaquin County JOB # 130 S L- REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID• TO DRIVEWAYS: <br /> (Applicant Name) STREET 51kYK <br /> AREA TU� QUADw <br /> fKi-27- TYPE L.&" Hat-E alsh t d <br /> (Mailing Address) FORMS 5AA416-1 <br /> NOTE <br /> S; A7 771V <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> ?� CALIFORNIA SUPPLE&ENT <br /> Com? '3= <br /> F3 <br /> The undersigned hereby applies for permission to.excavate, construct a i/oI' :e <br /> otherwise-encroa-. on-County Highway Right-of-Way--on-the �6S��'° _'">ei� of-4 - <br /> �7' <br /> approximate �� eet�/mile "' <br /> Of / 6.nA7� f�f&77 '• by "performing the <br /> following work (description of work) : <br /> 677-1 . <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 /> Signature of Applicant - Title Date <br /> pE'iURN�PiE�R�Mf TS.TO: <br /> I9ISZSR.PS\PSBS®L (6/00) • G&E <br /> .JOB PROCESSING DESK- BLD 1 li <br /> 4040~ LWW <br /> S OCKTON, CA 95204 <br />