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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of :Public Works APN CR # <br /> EXP. DATE ID- �D <br /> VALID &a Zf o1 TO /d•.L-0 DRIVEWAYS: <br /> (Applicant Name) STREET �d+1t!!t/JJt)G J9Yi�• <br /> AREA QUAD GcI.S <br /> (� C% Ll e7%T �,/�� TYPE SLG Wo 06AV 7 <br /> (Mailing Address) FORMS -7— <br /> s�Jc �✓ ��� 7 S�� �, NOTE <br /> (City, State, zip Code)V(Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> J oJ C/� -7 3 SHALL BE A5 PER <br /> ld6' �v 00 CUPPENT M1.U.T.C.O. <br /> CALIFOPNIA SUPPLEMENT <br /> RETLMN PERMITS TO: <br /> PGNE <br /> JOB PRWESSM DESK- SL® I <br /> 4W Wast Lan® <br /> STS WIDN, 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 � � side.of <br /> j) �j n/ln✓C� ��P approximately 304 � ee��s3-e- 4,1957- <br /> of v c/r f i c`L n by -per€orming the <br /> following work (description of work) : ). (� J✓vc� -e 11A,4,, an ✓� h' 4 X A 14 <br /> 1 X, <br /> �6 .f' S Px,S j✓I /. li P<" 1�n a�,c�C S S>vl, 11760 <br /> 4P, .y t iter' d o :+r ,,A <br /> Work will commence on or about 2- 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 /> G. --------------151A <br /> Signature of Applicant - Title t1�7 to <br /> MASTRR.PS\F2RSCHDL (6/00) <br />