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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date " ,� OFFICE USE ONLY <br /> TO: San Joaquin County JOB #f;cS L(a REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 1- J <br /> �j VALID 5 d TO X DRIVEW;Lys <br /> (Applicant Name) STREET 'CARROLL AUC= <br /> AREA MML<m L QUAD FS <br /> AJ. TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> Sfi�k o�✓ ��. 9.s'2o� <br /> (City, State, Zip Code) <br /> i <br /> cJ ¢Z- I!G4 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> /0L�3 Z 1s8 CURRENT M.U.T,C.D. <br /> CALIFORNIA SUPPLEMENT <br /> ten , errs TO: <br /> srm ,CA 9504 <br /> . <br /> The undersigned hereby applies for permission to,excavate, construct and/or <br /> otherwise-encroach on-County Highway Right-of-Way-ori they side.of <br /> C� LG approximately <br /> of /�/hS ir✓ -0 S s 1✓, , by "pez€or�ing she <br /> following work (description of work) : % �✓� el • G Q 6X. 4 4h <br /> wi T4s Pwi« /1 n c La-4- L L S <br /> Work will commence on or about l-47'5 for approximately <br /> L9 O 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 /> Ro�6 c,-T Gi,4e q <br /> s Z� ;eO14K �g <br /> Signature of Appl cant - Title S :01.WV p C ddv toll ate <br /> MASTER.PS\PSESCBDL (6/00) <br /> I <br />