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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6 -�� OFFICE USE ONLY <br /> To : San Joaquin County JOB # 7.30TZ. -(0 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID TO l-IL-oSi DRIVEWAYS <br /> (Applicant Name) STREET Sox--OP-A ST <br /> AREA 5Toc.45T2t---11 QUAD w S <br /> �`G�3 `/� • TYPE 79r-- 1{olE r "C���LEL <br /> (Mailing Address) Og FORMS �, WW , J�m-24 <br /> �( HiT)n , !� ��T�— 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 vrn <br /> ` %J ��,i► CURRENT M.U.T.C.D. o ' <br /> CALIFORNIA 5UPPLEMFNT a <br /> a <br /> r.*M <br /> a Q�0N <br /> am <br /> s om <br /> 0 C3 <br /> cn z <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> of rwise encroach on County Highway Right-of-Way on the fl side of <br /> e <br /> �'I, -'4-X),(lDr&' - approximately GI /�" feet/midi. ad—' ' <br /> of ,45) 4P��� '� 'yl� , by performing the <br /> following work (descripI Ll <br /> tion of work) : hc <br /> Work will commence on or about t-4 - for approximately <br /> 16c) 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 /> Si ature of Applicant - Title Date <br /> RETURN <br /> TMST P `IFEESCnL'L (b/OU) PEFOM TO: <br /> PGAE <br /> JOB PF O_ CESSAIG DESK- BW I <br /> QW /►L <br /> T <br />