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APPLICATION FOR. ENCROACHMENT PERMIT <br /> PLEASE PRINT. <br /> Date CJ OFFICE USE 0N1.;Y <br /> TO: Sar CountyJoaquin Couty JOB �� 73bS 2- REF ## <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID -/ TO Ze-1­07 DRIVEWAYS: <br /> (Applicant Name) STREE� <br /> AREA I�0,00 QUAD <br /> TYPE EGG ,1/vGE Tl�lt.!'N <br /> (Mailing Address) FORMS <br /> e---"r- 7 NOTE <br /> City, State, zip Code) <br /> L_Z_I�:;I / <br /> ( rea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> 01 SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RE UM PERMITS TO: <br /> 7 <br /> PROMSSM DESK- BLD I <br /> 4044 Wbst Land <br /> STOCKrON, CA 95204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-enc oach on County- Highway Right-of-Way oa tl�e/'✓'• 'Tra�J°`rTsi d�Sof <br /> Ll <br /> approximately <br /> of _,�C�' iQG°�rl;'I ate by "performin.gtthe <br /> following work (description of work) : � r&fit, <br /> oecr9me- <br /> Work will commence on or about ­' for approximately <br /> t� 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 O Z <br /> _c } <br /> Signature of Applicant - Title �£ y Date <br /> MA.STER.PS\FEE.SCSDL (6/00) - <br />