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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / G� OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> / <br /> EXP. DATE 7-1-5 ­D7 <br /> 7 <br /> 7 T-� VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET 14:;046e7?e _57: <br /> / AREA 5-rxAl QUAD <br /> TYPE qoLF <br /> r (Mailing Address) FORMS S-- <br /> NOTE <br /> (Ci y, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> p TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> 3S CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMrM TO: <br /> ,JOB PROMS8M DESK• BLD 1 <br /> s pe >> <br /> 4040 wftet LWO <br /> STOOcrON, CA moa <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise- encroach on County-Highway Right-of-Way-on-the )077r - side..of <br /> <24: approximately / / ee /M±tr 4,, j�'....,5 7_ <br /> of r,� Com ' /�' Qr!e , r✓. , . , by p forming the �.✓ <br /> following work (description of work) : s/ ', d <br /> f'Vx, &, 'ate ez -ux• v - "I► C_ <br /> �l� S�`V �"�3 arc ! �+.�> : ✓ x.93 . T _t <br /> Work will commence on or about �77 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 /> 31 ZA)7 <br /> Signature of Applicant - Title ZS :6V Otill ate <br /> yf <br /> MASTER.PS\HEESCEDL (6/00) 1 <br /> 3A <br />