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APPLICATION FOR ENCROACE-1�i-IENT PERMIT <br /> PLEASE PRINT: / <br /> Date it s/ v OFFICE. USE ONLY <br /> To San Joaquin County I JOB g FIEF <br /> De artment of Public Works APN CR: <br /> EXP. DATE !21/.310!0 <br /> VALID 9/$ D TO IZ O DRIVEWAYS <br /> (Applicant Name) STREETgN�•_c� <br /> u / <br /> AREA �.TacXLoN QUAD N 5 <br /> (� L%T7� TYPE -96ld, }bl:E <br /> (M_ai.?i_^_g Address) FORMS 5s,cuW <br /> S�Er v 64, 41 NOTE <br /> (City, State, .Zip Code) <br /> .209 -qq2 - _�6 0 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) ' 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, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the �<1 �j side of <br /> �i�Uti�ymY lcy (�)� approximately ( J feet/mile 150-0k <br /> of �' H14Vt S by perfcrmin the . <br /> following work. (description of work) : Cr���'f <br /> Work wil commence on or about /3 for approximately <br /> C <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 ana approval. <br /> Appi'icant - Title .atm <br /> RETURN PERMITS.TO: <br /> MASTER.PS\FEESCKDL rF/CO) �p . �PROCESSING �c+�� pp�� � <br /> DESK-aW 1 <br /> �Y� � L <br />