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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date L � ' ` 0 S12 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 4_7o SZ"Co REF # <br /> Department of Public Works APN A CR # <br /> EXP. DATE CJ <br /> VALID TO J DRIVEWAYS <br /> (Applicant Name) STREET ADELSegr AVE <br /> AREA SrM4ZMN QUAD ES <br /> L i CS• 1 Us Q.C TYPE OPS <br /> (Mailing Address) FORMS <br /> _ NOTE <br /> (City; State, .Zip Code) <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T-C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to-excavate, construct and/or <br /> otherwise-encroach on County. Highway Right-of-Way on_the _C—A,'>% - side.:of <br /> approximately 2(gslee mile Svy "'rN <br /> of - (z_w1 air— AA' c �rf✓��1=C�r.�l. performing the <br /> following work (description of: work) : — �{r-,L�� Br(„�I � t F=12 s <br /> ��C..C^ �\F-�•I t� � �fJK:.t=- G� �.�'-tom�--�?-'� �(�v _ _'C'7 - <br /> Work will commence on or about for approximately <br /> �-- <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 /> ap, a3a - <br /> ignature o= Applicant Title 10 :01 WV { Z 330 9002 Date <br /> MBSTM.PS\M=C=L (6100) <br /> Hiroo r -• •? <br /> Nin U } , <br /> (13A13.)38 <br />