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APPLICATION FOR ENCROACHMENT PERMIT <br /> ,PLEASEPRINT. <br /> Date �� / OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7 �Z-4o REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DATE /,q-/5-67 <br /> VALID Z-7_-6-7. TO /D-/S^07 c DRI' YS: <br /> (Applicant Name) STREET zVuAr�XAllek RA. <br /> AREA 5-rOC4-76W QUAD '* <br /> TYPE tt 14vtE 86 �rc1�XC-�r C <br /> (Mailing Address) FORMS 1.✓u7� ,ems��} ( <br /> NOTE -- <br /> (Olity, State, Zip Code) 7 'g <br /> LZ7 <br /> o <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TPAFFIC <br /> 3 ���a7/3_� SHALL BE AS PER L PLAN <br /> G g�' 76 CURRENT M.U.T,C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: S;'e, se,(641,PGM <br /> JOB PROCESSING DESK- BLD 1 <br /> 4W~tine <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way.on-the '. side of - <br /> approximately �eet nt. %�i'S l <br /> of /,0e, 4z,.?. , N. b erformiri the <br /> : . y -p � gi <br /> following work (description of work) : L / ✓ a J ' <br /> �a �✓ ST, I <br /> ,'vN ri/ <br /> a zmalr ise <br /> Work will commence on or about 7 o,7 for approximately <br /> Qcl <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 /> 163✓e-- �/�� <br /> X�) <br /> Signature of Applicant - Title to <br /> MABTER.PS\FEESCE3)L (6/00) <br /> it <br /> i <br />