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APPLICATION FOR ENCROAC12,1ENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> L `OFFICE ,USE {ONT_Y <br /> To: San Joacruin County JOB :a j - CQ <br /> RED <br /> Department_ /of Public works -pN CR: n <br /> EXP- DATE 49 <br /> VALID I <br /> TO DRIVEWAYS: <br /> (Applicant Name) STREET ?CJ <br /> C * ; <br /> TYPE /4)zz �" .ex)C IV <br /> (Mailing Address) FORMS S''S <br /> /_yw .9 <br /> � 4- 1 � �� NOTE <br /> J <br /> (City, State, Zip Code) <br /> ,(Area Code .- Telephone Number) <br /> r y <br /> Sketch (Detailed plans may be submitted) ,° c <br /> 3'6.14 <br /> & <br /> ✓4o / ( / 724 <br /> a <br /> TRAFFIC'CONTROL PLAN <br /> SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. x -- <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 th A411cny side of <br /> approximately / 3 _ _<zgRIE64:-e •j/� <br /> of XC! - 57 7E'/✓, by performing the <br /> following work (description of ork) : /V .n/ P_ <br /> f <br /> Work will commence on or about 3 / d 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 /> S=y<ia i:.Ii2 vi AYpli�.cit -- Ti tit date <br /> MASTE2.BS'•,FEESC-OL !6/001 RETURN PERMITS TO. . <br /> -MB PROCESSING DESK-BLD 1 <br /> 4040 ST(TON, Lam <br /> 04 <br />