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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date v OFFICE USE ONLY <br /> TO: San Joaquin County JOB # e7505ol-L REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE , 15­1,07VALID /TO 'c)'7 DRIVEWAYS: <br /> (Applicant Name) * <br /> AREA �i0 QUAD <br /> TYPE Elt �Ol� <br /> (Mailing Address) FORMS S . e-Z <br /> 11 <br /> NOTE <br /> ��!d2�� <br /> City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> `� TRAFFIC CONTROL PLAN <br /> * J'7G� 5 Z�4 SHALL BE AS PER <br /> '1�2 106 o7(-,� CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO:. /' ) <br /> JOB PROCESPGM�N�3 DESK.- BLD 'I fe e, <br /> 4040~UVW <br /> S I OCKMN, CA 95204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise e croach on County Highway Right-of-Way ori-the <br /> approximately < /mileo '�"� <br /> of �1�.Q,� .�'1�� � " ✓V / byper€ormirig tlhe <br /> following work (description of work) : i C' �rZ lLv/ cz vX. 1 <br /> X =nJ 16" G i <br /> Al <br /> J <br /> Work will commence on or about 2>/ J 7 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 /> ,23L(;7 <br /> L . _r T �. Title <br /> Signature of Applica"n"t - ,.��le �Z d � �Z B to <br /> MASTER.PS\nRS®L (6/00) _. <br /> I <br />