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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # �� Com ' REF # <br /> Department of :Public Works APN CR # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET IL Ay F_ <br /> / AREA �7 Y- . QUAD A/_5 <br /> Z <br /> TYPE Lt Haste Tf'AJCt4 <br /> (Mailing Address) FORMS 'S-S L <br /> NOTE <br /> �G�� ,��: ' .5 204- <br /> (Cit , State, Zip Code) <br /> i <br /> ( <br /> 2&tCode - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> Qv SHALL BE AS PER <br /> 7 � CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> "'PG&E T®: <br /> 31 ,3(p 1 PCid`EESSM DESK- BLD 1 <br /> 4040 WOM L M <br /> STOOCTON, CA 05204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherw'se encroach on County Highway Right-of-Way on-the side.of <br /> approximately (feee �1w� <br /> of /��� �#!�.?�"►QP� S�"i�Y!/. ' by -pe <br /> /shr ormjirig the <br /> following work (descr ption of work) : +? / 1)1 Uk• �X ' <br /> /�'/ P 'fir <br /> Work wicommence on or about 4o for approximately <br /> -- U 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 /> MASTSR.PS\nESCRDL (6/00) <br /> :8 J <br /> i <br />