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APPLICATION FOR ENCROACHMENT PERMIT R F C I ED <br /> PLEASE PRINT: <br /> �D� 2cas mAy 15 AM 11: 43 <br /> Date �J OFFICE USE ON7,Y., <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN ' ° { `<tt ' t t,.4 s 'CR # <br /> 69EXP. DACE � / / O� � <br /> VALID d TO / 67 DRIVPWAXS <br /> (Applicant Name) STREET -.i; t j <br /> ,,��LL AREATitGtl +QUAD * � <br /> Q � d /4� TYPE Vie// lao QS k"rp"wXes <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 /> S- ALC BE X45 PER : .� <br /> CURRENT ISA U.T.C.D. <br /> CALIFQRNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or' <br /> otherwise encroach on County Highway Ri ht-of-Wa +on �;the , <br /> of <br /> fapproximate. <br /> ,UP <br /> of ~ by 1performz lg the <br /> follow'ng work (description of ork) : <br /> Work will commence on or about " •DG. 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 /> 4&N - zf',b"f 6&(:2 r oma <br /> Si ature of Applicant - Title Date <br /> RETUM <br /> MAST P \FEESCHLL (6/00) K TO: <br /> 4040 <br /> STOC "Of <br /> CA 95204 <br /> \ <br />