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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �7 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> TO /S'�? DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 27491 QUAD AVIV <br /> �U (�PS7" . �1�(�• TYPE_315LG //0,&15, RerJJe-4kA5* <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> 4-Z. <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �m � ,3U.�.��'�D✓� - . TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> /UZ Z$S8L'. CURRENT M,U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO'- <br /> Pau <br /> O»Pau <br /> JOB PRWESW40 DESK <br /> 8MUM GA 9&W4 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> oth�e-encroach on County Highway Right-of-Way-on-the F.GS side5.of <br /> ve _ approximately 4 0 Z 8 e mile �t/DI�y <br /> of GAJ by "perform3xig the <br /> following work (description of work) : Z2) be/lye e 000(aX- 4�� ¢ !.✓ ®�`r47J <br /> 7- .4rvb 0'y 2 9' i./ Di AT I l-I 0"q0C-4 Z-e xe <br /> ��js�+� -f•9c; 1 �-t' yes a,,o vroyi ;As Service-, <br /> /y- 177)6rk 61RQVe 1 . nJ /-60;- <br /> Work will commence on or about Z U 7 for approximately <br /> �D <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 /> /�0 6e'-rr G I-RV <br /> �bS KFIA y;,7 1.-'. 51010 <br /> Signature of Applicant - Title ;01 r_ � + LUZ L— Dat® <br /> MAST3R.PS\F=SCE0L (6/00) <br /> 1 <br />