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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date S' Z.S�' !/� OFFICE USE ONLY <br /> To: San Joaquin County JOB # -(s REF # <br /> Department of Public Works APN CR # <br /> EXP- DATE <br /> VALID '7-/9-00 TO 1-0-0(, DRIVEWAYS: <br /> (Applicant Name) STREET BLAC4c Sta1VE Dom. <br /> AREA 794c' QUAD L <br /> JDS ?9Det-3-6*IL We5'TLN. TYPE 'T%6NL" <br /> (Mailing Address) FORMS SSS 6OW <br /> NOTE <br /> (City, State, Zip Code) <br /> 109- <br /> t Cn(Ary,ea Code - Telephone Number) <br /> N cc <br /> •= 0 <br /> W ke=h �petailed plans may be submitted) <br /> } "M _ TRAFFIC CONTROL PLAN <br /> V o SHALL BE AS PER <br /> LU - C"� CURRENT M.U.T.C.D. <br /> CM <br /> cc <br /> .ec <br /> o CALIFORNIA SUPPLEMENT <br /> a <br /> N W <br /> -p . ' <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> . otherwise encroachQn County Highway Right-of-Way on the Ale Ag ;i/ side of <br /> .BL 4 cw-S70rClA. 1 ice, approximately `��� feet/-u-i-3-� EAS7 <br /> of P-CbaR.I DLE )et)- by performing the <br /> following work (description of work) : Z;/b5a1RLK <br /> FDlZ 70 � -fa �n1S7sl L L �G�'C7lZ�L� QAC 1 c. 1 T/�'4. <br /> Work will commence on or about .SE 107. Z.DG tfor approximately <br /> 4AJ L5 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 /> Signatura o� A glicant - Titles Date <br /> RETURN PERMITS TO: <br /> MASTEH.PS'%FEESC1IDL (6/00) QPGM <br /> JOB PROCESSM DESK-BLD 1 <br /> Q 40Lm <br /> {40 V g ia <br />