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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date '.Zzg/ OFFICE IISS ONLY <br /> To: San Joaquin County JOB # q 30.SZ = ( REF # <br /> Department of Public Works APN CR # <br /> --� �• _ ) � <br /> EXP. DATE <br /> VALID• TO DRIVEWAYS: <br /> (Applicant Name) STREET #kfV F9 reWr hE ZMZ:, <br /> /� �j AREA AC4AW QUAD A'E <br /> -7 (�7`'G TYPE -Au?*-; �' -Mew-i4 <br /> (Mailing Address) FORMS 6Vjed/. A—f --Z1Z <br /> l' NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> jr�eL� � G j TRAFFIC CONTROL PLAN <br /> 1� /t SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: <br /> PGMrn <br /> .,JOB PROCE88M.DESK- BLD 1 <br /> 4040 Wit L" IW 7,. W /OZ07a 5.Z Q <br /> 81 OOKTON,CA 96204 <br /> The undersigned hereby applies for permission to.excavate, .construct and/d+ <br /> otherwise o -County Highway Right-of-Way oa the fCh57- aide.:of <br /> i w' approximately X/i,Q_ ee /ets�e /✓� <br /> Of e 'E? GC/!► T✓Pf i0 ccd , by <br /> -per€orming the <br /> following work (description of,.work) : i'c vrtee // a/ vX• ' ' 'IV v 41 e <br /> eZP - �"Cj 1711- ilG� o 'OVPttJ �C- <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 /> e Q zr_t saga �Z /S P <br /> Signature of Applicant Title ate <br /> NASPSR.PS\PR=C6DL (6/00) l S •6 Nd 61. 330 9002 <br /> .�•t f:t1 � Via 1 f143 v ' � -' <br /> 03A13036 j <br />