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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE 1\' i- <br /> � . VALID Q-13-d'7 TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> �L) -7- AREA L-7�Q� u QUAD F'S <br /> 2_1'V' TYPE amu-HOeE 5� QE: t"ri2EAC94 <br /> (Mailing Address) FORMS <br /> C.�-1 NOTE <br /> City, State, Zip Code) <br /> �Z0 q �S�Lt ¢ <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed planes may be submitted) TRAFFIC CONTROL PLAN <br /> �� 3US7.31�0 SHALL BE AS PER <br /> wvT /,-)Z 341 Z4 7 CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERM"TO:PGAE <br /> l <br /> jos PROCESSING DESK_.BLD I <br /> 4040 West UM" <br /> STOCKTON, 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 G✓-eST sid .of <br /> S a ale Ave• -y-- approximately 9 e /mile AIM;r# <br /> of _f��/!f/A✓GToAl -; `� � GAG ui✓ by perfo ing the <br /> following work (description ofork) : o O G ov. 4'X A .✓ PVA <br /> C X• ' � 1.x'1 CAAAor . a ` ;W11dJDMo .0 SJ <br /> -OV,s- i' c ;c s avb aV' s mac. `--t` r 1 <br /> Work will commence on or about for approximately <br /> 00 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 /> -L.'Rig <br /> j''4'�,��C��`•�-_�_ Gas ,�,`���� :�,, ,, ,� - �7 U 7 <br /> Signature of Applicant - Title {)1� ;Of "j(' f 1iii7 ate <br /> MASTER.PS\EBBS®L (6/00) _ i <br />