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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date �n12�f(��1� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> ATE <br /> VALID <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET fiA'P-9koNT Am. <br /> AREA 57. OCXM^N QUAD 0)e-- <br /> TYPE <br /> TYPE BELL-J40 ..E Sc.%G <br /> (Mailing Address) FORMS 5Z)/[tlrJ -P -7-J <br /> NOTE... <br /> (City, State, Zip Code) <br /> nAt - 1&e-1 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLA o <br /> SHALL BE AS PER -+ o <br /> CURRENT M.U.T.C.D. C-) f <br /> CALIFORNIA SUPPLEME'N'T N 0 <br /> c .c- rn <br /> 3,, z 4C <br /> ornu` <br /> o ,. c <br /> PM:':0 52 588 � w <br /> t o loZoolG"ll� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ' <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> r&4(' approximately feet/rzi-.�= "66U4i-% <br /> of V� �..+�- , by performin the <br /> following ork_ descri tion of work) V1 Q,lJ <br /> 6=L(e- �rL�l [�(�. 3325 aA ak PWf- <br /> Work will commence on or about for approximately <br /> t ^ <br /> C� 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 /> a0c - I bT (w, 66ahr <br /> 1 <br /> Si atR�uRN PERMITS TO: <br /> ure of Applicant - Title Date <br /> tMST .-P \FEESCiIDL (6/00) • " <br /> JOB PROLE-SSNG DESK-BLD 1 <br /> 1 4040 West Lana <br /> S.� , CA 95204 <br />