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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - t ' ^OC2 OFFICE USE ONLY <br /> To : San Joaquin County JOB # 730Sz 4, REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 3 r <br /> VALID TO Q DRIVEWAYS: <br /> (Applicant Flame) STREET � <br /> "•-- J /, y� �� 4,kr QUAD <br /> TY �PE Adm <br /> (Mailing Address) FORMS <br /> n , 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. v c <br /> CALIFORNIA SUPPLEMEIVTp, <br /> 0 <br /> C: <br /> a) <br /> =C csrr+ <br /> The undersigned hereby applies for permission to excavate, onstruct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> Of <br /> _ approximatel 29 ' feet/� W/G <br /> 1r14 As�� by perfo min the <br /> fol owin work (description of work) : lin I <br /> Work will commence on or about for approximately <br /> lam- 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 /> (,�u, ��tmwbr <br /> Si ature of Applicant - Title Date <br /> tgAST \FEESCiu7L (e/GV) �� MM C TO. - <br /> 4W WON Lam <br /> v 7 VCKMN, CA 95204 <br /> \ <br />