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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> r <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # :�'30 5REF # <br /> Department of Public Works APN CR' ' # <br /> /- <br /> EXP. DATE <br /> VALIDTO DRIVEWAYS: <br /> (Applicant Name) STREET !�Tjz <br /> �L2 1, /�S�„ j AREA .154,,NgRa QUAD AW <br /> _ ,—a /i TYPE 13F.l.C. 1(011► • r <br /> (M/ailingMC�Address} FORMS �4t1GJ �,(�-� <br /> JO ✓V, C�Y /� ��� -NOTE <br /> ( ity, State, Zip Code) <br /> c Q47 <br /> w <br /> (Area Code - Telephone Number) ci srn <br /> ZZ <br /> Sketch (Detailed plans may be submitted) `: r- <br /> •J7 TRAFFIC CONTROL PLAIN <br /> SHALL BE AS PER <br /> ��/,• �� CURRENT M.U.T,C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO; <br /> POM <br /> JOB PROCE88M DESK- BLD <br /> 4040 Vftw Lam <br /> STOCXTON, Cry 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County-Highway Right-of-Wa ..oxo"t1e ��d. � side.of <br /> �� approximatel <br /> of <br /> following <br /> work (description o�fj work) by "p/er€ormirJ <br /> g the <br /> (f�_7(_Wh,7 //? '(-CL. OL/ /:1� <br /> 7` `ri' /✓%� �/��' <s� � l�I�( �L.f�l�d(/?l°, !G L a /� � ` �1 <br /> )AI T i/t/ a'i /,'e'te/ `�'Q�S �U CQ fi <br /> Work will commence on. or about .371-5-1,.)7 for approximately <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 and approval. <br /> Signature of Applicant - Title D to <br /> MASTER.PS\FEES®L (6/00) - <br /> i <br />