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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- / <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB #_1 .VJt2��o REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT G <br /> VALID S O <br /> DRIVEWAYS: <br /> (Applicant Name) STREET e/�wae <br /> AREA 7�aGkl.0n QUAD AI/5 <br /> (�(�•7- TYPE gg-/G,litiG6 f -rje,, x--H <br /> (Mailing Address) FORMS <br /> 04- NOTE <br /> (City, State, Zip Code) <br /> Lei n A e - 1&f6l, <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER (s <br /> CURRENT M.U.T.C.D. m o ' <br /> CALIFORNIA SUPPLEMENT y � <br /> rn <br /> c crn <br /> -1z <br /> Q© <br /> 1 �o l0'Lo57 o <br /> tI� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwie engroac4 on County Highway Right-of-Wa on the (> side of <br /> had- K4 4fA <br /> approximately feet/nf#= 1�41; <br /> ofT <br /> y perfor in <br /> following work_ (description of work) : FLIO <br /> AbWZ A+71 Z444 biruAAle- ffilc <br /> Work will commence on or aboutfor approximately <br /> 80 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 6&6? • 'LS •off <br /> Si ature of Applicant - Title Date <br /> errs To: <br /> tMST c \FEESC:tiDL (6/u0) �Q ppOCE PME <br /> 4M DESK L^ <br /> Lam <br /> STOCKMN, CA 95W4 <br />