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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f �'� OFFICE USE ONLY <br /> To: San Joaquin County JOB # �J�SZ�Q REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE /2--l r-07 <br /> / 1 y z <br /> VALID ,?-49-07 TO DRIVEWAYS: <br /> (Applicant Name) STREET y6f/ ,16i?Mr-) L <br /> AD- <br /> AREA QUAD Al <br /> TYPE BEGS Nam 7-A-K r—H <br /> (Mailing Address) FORMS SS wu', LS <br /> NOTE <br /> k ity, State, Zip Code) _ <br /> (ixea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> �T / SHALL BE AS PER <br /> 3¢ j �/ CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETUM PERMITS TO: <br /> PGAE <br /> joe PRCC+ES894G DESK-BLD I <br /> STOCKrON, CA 96204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroachn Co ty Highway Right-of-Wa on-the /���-- side.of <br /> �`S Gt/ f v✓I (�� approximately <br /> of S-C&' by per€grm'Wt he <br /> follow* work (description of work) : iCa v!�t� L'/ �' a w 4 N� <br /> G✓ ��C� �(�. �� � : i✓ � CGP_ iS" 'r? 4 i "P <br /> IZ ,::;77 41, <br /> Work wil commence on or about for approximately <br /> 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 /> 6X) <br /> Signature of Applicant - Title c 0 :010 J G A"j1 i a z ate <br /> MASTER.PS\PEES®L (6/00) <br /> I\ <br />