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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date v OFFICE USE ONLY <br /> r <br /> To: San Joaquin County JOB # � REF # <br /> Department of Public Works APN CR # <br /> EXP. D746 <br /> 3 � <br /> p` VALID 2767 T 3717,119 DRIVEWAYS: <br /> (Applicant Name) STREET�A D GJni D <br /> AREA 41A oyY )9 QUAD "- <br /> 4040 (�(/�J � Z�' TYPE ��LL NO LE rY2�JJCIL <br /> (Mailing Address) FORMS <br /> NOTE <br /> City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 3d5-754694 <br /> SHALL BE A5 PER <br /> /z/hj,-li- I dZ 3504-3.t5- CURRENT M.U.T.C.D. <br /> CALIFORNIA N <br /> SUPP <br /> RETURNREITS TO: �c <br /> j0SRROCESWG DESK- BLD 1 <br /> 4040 W69 Lens . ''— <br /> STOCKTON, CA 96244 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County- Highway Right-of-Way-on-the Aldside.of <br /> /�D•k'��G �� RL'., approximatelyfeet mile 1.41�51 <br /> of �r457-Z .c7�r/ y perform}rig the <br /> following wor (description of work) : % <br /> �rIG GG �vX� Z Jt� .e oIV6,e <br /> P <br /> y /r✓D nAJ 'n/ �4.F11� <br /> Work will commence on or about 2 7 U 7 for approximately <br /> �D CCS 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 - Title4 + � f Date <br /> lWSTER.PS\FEESCODL (6/00) <br /> v li <br />