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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> / V OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN //9' 63/ —oz CR # <br /> EXP. DATE <br /> VALID 94"/V_7 TO /o/G/°? DRIVEWAYS:. <br /> (Applicant Name) STREET <br /> AREA 5'tG 4t tJ QUAD NE <br /> TYPE Ap,V lAl le , Akglg Tib h <br /> (Mailing Address) FORMS /Z-Z 9 <br /> NOTE <br /> 2<0o,4 <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> /l Z3 SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETLMN pERMIiTS TO: <br /> JOB PROCESS04G DESK- B1.D 1 `— <br /> awns <br /> STAGICI'CaMh, CA 96204 _---� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on theeLfFtlsidesof <br /> approximately ee /mile S <br /> of 5,4nil,44 j^✓e L n/. _ S�' `y "per€ormin� the <br /> following work (description of work) : <br /> �r/i✓�S b v�?L OrDO r o:l. yv y✓e- .c✓76 a 2 'r✓ <br /> -�v f'IGa Rz z 7 <br /> Work will commence on or about for approximately <br /> ADO 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 /> Signature of Applicant Title OZ ,01 WV 91, ..V .I; LUZ Date <br /> MASTER.PS\FEESCHDL (6/00) <br /> I <br /> i <br />