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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5 7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7 365 Z-�o REF # <br /> Department of Public Works APN -� CR # <br /> EXP. DATE 7-e> <br /> VALID TO 9-1-67 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 5- r_K-ro J QUAD SS <br /> TYPE -3E N _ <br /> (Mailing Address) FORMS 'S� www Z9 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 7/�c� <br /> 3 SHALL BE AS PER <br /> -3 Zd yf O CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: <br /> PGM <br /> JOB PROCESSM DESK- BLD I4040 VftW Lane <br /> _ <br /> 8OCKTON, CA 95204 <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the �E-4 S-)- side of - <br /> l�� p✓� approximatel /n/�i2T-�/ <br /> of _ � �✓ by "performing the <br /> following work (description of work) : n/<_ .� //h� dK. 4�%n/ ✓i✓I <br /> l .s S�/c • a <br /> Work will commence on or about S v for approximately* <br /> O <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 /> �o�cr7 Z_i aA <br /> c) r <br /> ignature of Applicant - Title 'U1 WV Date <br /> MASTER.PS\FB3SC3DL (6/00) - <br /> :7 a r <br /> i <br />