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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT., <br /> Date v 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> r VALID 4-17_o-) TO J-i 5-y'7 DRIVEWAYS. <br /> (Applicant Name) STREET `�rko RU. <br /> _ AREA F ?mid CAAf <br /> `tQUAD 5 <br /> 0 W'Q 7 r L-9✓ TYPE 6 u_i4 o'er <br /> (Mailing Address) FORMS _554,,, I� Zn1 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETUM PERMITS TO: <br /> PGM / <br /> JOB PROCESSM DESK- BLD 1 <br /> 4040 V 0 1 Lane <br /> OCI ON, CA 95204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way- on-tyhe ,'vtV7,11 Lti6'1f1',W sides of <br /> G!/• ��: approximately 0-70. ee /mTte !eXS l <br /> of j- by-performing the <br /> following work (description of. work) <br /> -k_, ' o lE e % f✓ ('i9 E' nib' ` r ,.J,; <br /> <i? e.N7 '.� Y <br /> Work will commence on or about 412lo-Z for approximately <br /> Z-2 _ 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 - Title1 (/ <br /> ZS :6 Wb QZ b VN L0fl1 ata <br /> MASTSR.PS\FUSCHDL (6/00) _ d i^:7�5 1 ,\ <br /> t <br /> 13.'0 ^,6; <br />