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APPLICATION Fad ENCROACHMENT PERMIT <br /> PLEASE PRINT: - <br /> Date �/ 9�J/ OFFICE USE ONLY <br /> To: San Joaquin County JOB _ REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT <br /> VALID , Z&7 TO fo-iS-07 DRIVEWAYS <br /> (Applicant Name) STREET AVI"W l Gds_ <br /> // AREA ST.�,rI QUAD (/• <br /> It l e Sr L,,,/ TYPE <br /> (Mailing Address) FORMS <br /> L NOTE <br /> (ci y, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 30��330� SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: <br /> joe PROCESSMG DESK-SUS <br /> 404o Wag LWW . <br /> STOCK ON, C^95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the ,,_4W57-_.tC-Zk4! 57—- sides of - <br /> Ren/ faVe , approximately ee mile <br /> of by "performing the <br /> following work (description of work) : .6, On/e vK/, 4 X ✓✓ <br /> ,pvi/l <br /> 14'JIV5?Pi2RoY, I9 ' IAI 7' ;A,/ D o a c Q- S <br /> n IJ AG i / rrS ✓V /r'ovir� rGJ s S✓G• /72W L> ✓l� <br /> Work will commence on or about// // -- d for approximately <br /> days <br /> `/Gi 7 Its' - -- <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 s� z4 :I I WV C f d� LOR Date <br /> MASTER.PS\FEES®L (6/00) <br /> C1 Aij:) <br /> i <br />