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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date — � "� � OFFICE USE ONLY <br /> To: San Joaquin County JOB #_750 50-�co REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID Z-!$-O TO 03-16-61 DRIVEWAYS <br /> (Applicant Name) STREET ({OJJIEK -5r. <br /> AREA A:�md= QUAD A-IF <br /> o 4o W I,- :J TYPE "8 GG ,ytoLE BOA <br /> (Mailing Address) FORMSlr1LU 29 <br /> NOTE <br /> (City, State, Zip Code) <br /> "s A-_Z- <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 /> F-C �� L C, 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 CA. side.of <br /> �j approximately t t ee /mile 5C1-T'A+ <br /> of by "per€ormirig the <br /> following work (description of work) : !9; ! u t <br /> - <br /> =�Z <br /> -�-- <br /> work will commence on or aboutfor approximately <br /> Z-- 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 /> AiDe <br /> Signature of Applicant - Title SQ :DI WV 1 _ 93J LOUZ Date <br /> [+67nM.PS\FnSCBDL (6/00) L''� <br /> aA1]10 <br /> i <br />