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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEAGE PRINT: <br /> Date __ OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 75017--11:o REF # <br /> Department of Public Works APN CR # <br /> • _ EXP. DATE � <br /> 6VALID [ TO 07 DRIVEWAYS: <br /> (Applicant Name) STREET O� <br /> / AREA S9LeJ: 9V QUAD <br /> :5r- <br /> TYPEC <br /> (Mailing Address) FORMS <br /> _ NOTE <br /> —�--(City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans //may// be submitted) TRAFFIC CONTROL PLAN <br /> IC <br /> L/6 eX e, J <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: p✓?'y _346 4 500 Z <br /> PGG <br /> JOB PROCE881NO DESK- BLD 1 �/�>- # /JZ Z ,.5 4 Zo 5�-- <br /> 4040~Lens <br /> STOCKTON, CA 96204 . <br /> 4 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on Count Highway Right -the �i-i.7.'# side-of <br /> County-.- J Y 5 <br /> ee <br /> 'eapproximatelyfee /mile _;,2LI7 <br /> of v30 ST +✓ by "performin g the <br /> followin work (description of, work) : '1 off: <br /> . <br /> /S/ <br /> Work will commence on or about c: 7 for approximately <br /> ?CJ 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 /> r <br /> Signature of Applicant - Title I " � �_ ��r` �O� Date <br /> (6/00) .^ <br /> A13, <br />