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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 11 6 OFFICE USE ONLY <br /> To: San Joaquin County JOB # ?3652-( REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> /", G, VALID• TO DRIVEWAYS <br /> (Applicant Name) STREET BtJl,g AVF— <br /> AREA 577yucroti QUAD N5 <br /> _�_l/Y'D !/"� LI✓, TYPE _"Bet t. kOLS , BoRE �.�fil/GN* <br /> (Mailing Address) FORMS 55TWw, F--Z9 <br /> NOTE <br /> City, State, Zip Code) <br /> z /,: <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> • �{� �j���) ���� SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETUM PERMITS T4: � D.�3 70,37 <br /> JOB pFOMS oESK- SLD i ,voT <br /> 4wo vfte Lmw <br /> STOWTON, CA 9504 <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwie -encroach on County Highway Right-of-Way-on-the 4�X"4 side$.of <br /> 'FL approximately 2 SV ee /mile ma/ ?T <br /> of 8i4l�� S�� S�' by "peY€ormin,q the <br /> following work (description of work) : ave, 6Zk1A61z ex _n <br /> Work will commence on or aboutUs for approximately <br /> 07 <br /> :012 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 a}'pro al. <br /> e,P7-�i�q - <br /> /�C x-�ps ®��, !1 f . r.. •I d 3 C . Z 1� d <br /> Signature of Applicant Title OS '6 NV 6 1330 9001 Dat <br /> HAS=.PS\FBBS®L (6100) v <br /> a3A13.03 <br /> i <br />