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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> _ <br /> EXP. DATE _ _5__ate-� <br /> lt' e�E. VALID 5---091-67 TO DRIVEWAYS <br /> (Applicant Name) STREET � H <br /> AREA fW NCN AD S <br /> 4�2440 L`Ves—F Znl, TYPE 'C?"--LJ-HOS & � _ Ti NC <br /> (Mailing Address) FORMS <br /> �z NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> _ •� TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> Z, Z'(p; s.J� CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> P e C <br /> JOB PFOCESSNG DMK..Bw I <br /> .4040 wr t LOW . <br /> STOOKION, CA 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> othevwis encroach on County.-Highway Right-of-Way"on.the CSS 7 sido.of <br /> approximately 4 79� e�e Mlle _/t/�J�C'Ty <br /> of by performing the <br /> following work (description of work) : %- P. 1?�� O'" (�i� 4''X w •e'vi `l <br /> G�i�la�af iSc, �� <br /> Work will commence on or about _ 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 /> kO 6e,7 Z- <br /> Title <br /> at® <br /> Signature of Applicant - �� <br /> MASTSR.PS\MMSCR0L (6/00) <br /> ! <br /> `T .A A r <br /> I <br />