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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date ?' 'OG OFFICE USE ONLY <br /> To: San Joaquin Count ------ --- - <br /> q Y JOB # 73oSZ-w REF # <br /> Department of Public Works APN CR' # <br /> i /� <br /> EXP. DATE z O(a <br /> l C-- VALID O(o TO Z J Off. DRIVEWAYS: <br /> (Applicant Name) STREET _"ToAk) Ay-6 <br /> /,y. AREA QUAD 15 9 l�iCJ� TYPE"164G hpa' AXR <br /> (Mailing Address) ^A 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, ponstruct and/or <br /> otherwise encroach on Country Highway Right-of-Way on the ' _ side of <br /> -CX�1�� approximately feet/tea Q:�+ <br /> of _ ( _��e by performin the <br /> following work (des ri tion f w rk : <br /> Workwillcommence on or about 24. 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 /> 14 <br /> Si ature of Applicant - Title Date <br /> MAST -P \FEESCHDL (6/00) RETUM PG&E <br /> PERMS�,CTO: <br /> • <br /> e C 95204 <br />