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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB #_23Q5_2-_(OREF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID / o TO 97 07 DRIV$OJAYS <br /> (Applicant Name) STREET C A <br /> AREA t 1t_ Al 4U� <br /> TYPEf�40 L T2w&3r-u. 86)2E* <br /> (Mailing Address) FORMS SSI W 2-24 <br /> NOTE <br /> City, State, Zip Code) <br /> '59) ¢ 7- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> 37d S—& ���9 SHALL BE AS PER <br /> CURRENT M.u.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: lL <br /> PG&E <br /> ::jOB PROCESSING; DESK- BLD 1 <br /> 4040 Vlhst UA a �--- <br /> STOOKYON, CA 95204 <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on she side of '> <br /> 6�1/)7,3 X I/,5, approximately 5 I eet <br /> of n/D�1 57� y "performirig the <br /> following work (description of work)� A Ro�� d ►'� <br /> 4^1e_ e,,6 A Q (UX, �5 o ry DSP ai/1/J� ,r%JS - <br /> Jrpl/11 S' i/✓ 6<1&e P i <br /> ivu.J ��S'i�E',nc� Z S cG,.�3 ..Ove• 'v <br /> Work will commence on or about 6 for approximately <br /> 9� days. - <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> ,,4e'T-7— Z eq <br /> _Q!,1),1%1 -,�nn Z�j <br /> Z ,a "T Date <br /> Signature of Applicant - iitiE LIJ$f LOU <br /> MAST9R.PS\FHHS®L (6/00) <br /> j E:� 'j <br />