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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _`kD 0_7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73p!5 Z-(o REF # <br /> Department of Public Works APN CR # <br /> _ <br /> EXP. DATE <br /> VALID 6-IS--a7 TO 7-/-0'7 DRIVEWAYS: <br /> (Applicant Name) STREET PGNY"Al 1945- <br /> AREA 5,me_L'nA/ QUAD WS <br /> TYPE '50t HOLE J( Vbtsy¢� <br /> (Mailing Address) FORMS '9 1_,yW, le-11 <br /> 'CU C 'r0 <br /> NOTE <br /> CA- Z <br /> (City, btate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> . TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> E`esiz— `YO CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> � J -3Z_ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on-the 5,'&.v VA side, of <br /> C.(t -_k approximately J"L eet mile e AS d <br /> of -y-is by "performing the <br /> following work (description of, work) : 1 V-2." <br /> .�i„S pA�c Nim..►� '" <br /> PYk 3c>!54a 3z,78 <br /> Work will commence on or about w i' 'O for approximately <br /> 7s- <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 /> S' ature of Applicant - Title Ot $ 4 Date <br /> MASTER.PS\FEES®L (6/00) <br /> i <br />