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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7,50S Z-(e REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> (-� VALID -lo-c 7 TO DRIVEWAYS: <br /> (Applicant Name) STREET CARPeWrdR W0. <br /> 7��� (�C/CS7" Gr'✓ AREA 57rack7'61.) QUAD * <br /> TYPE S0-ee_.y'O'e'6 <br /> (Mailing Address) FORMS :v1 <br /> NOTE <br /> ity, State, Zip Code) <br /> (—Zdq) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> /Z'm .,le 7 7 TRAFFIC CONTROL PLAN <br /> Av .'-d 100_339e_-7? SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETU M PERMITS TO: <br /> PGM <br /> JOB PROMSSM G DESK- BLD I <br /> 4W~ Lane <br /> S I OCKTON, CA 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach or; County Highway Right-of-Way on-the &OZ;rl- ) side of <br /> of G� r'�G D <br /> approximately ee /m4a� Zif5 - <br /> by performing the <br /> following work (description of work) : ¢";W <br /> /!Cw horrrG bcts�rl ss ,✓}' <br /> Work will commence on or about o7 for approximately <br /> /Z 0 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 /> wwl <br /> 0 <br /> Signature of Applicant: - Title <br /> 92 :010 9 - T <br /> i(' Date <br /> M%STER.PS\FRES®L (6100) - - <br />