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APPLICATION FOR ENCROACM4= PERMIT <br /> PLEASE PRINT: <br /> Date - ( 0), Q.-7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 752-CP REF # <br /> Department of Public Works . APN '�� CR # <br /> F� EXP. DATE /Z'Y <br /> VALID• TO 12-1-0-7 DRIVEWAYS <br /> —�— (Applicant Name.) STREET 8NA: -419, <br /> l t` p AREA Cicero•✓ QUAD <br /> A ' V�l.r _ TYPE 'F tG XdLE <br /> (Mai-ling Address) FORMS. <br /> NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephone Number).. <br /> Sketch, (Detailed plans may be submitted) <br /> . .- :T PLAN <br /> SHALL BE AS PER <br /> r CURRENT M.U.T.C.D. <br /> �C CALIFORNIA SUPPLEMENT <br /> 4o'-, 9 Zb(o <br /> The undersigned hereby applies for permission to.excavate, .construct and/or <br /> otherwise-encroach-on County-Highway. Right-of-W&y-•on-the <br /> approximately f eet/m*§!e W <br /> Of itu C F�'n> '�i C IS by pe'rf orming the <br /> following work (description of:work).: -A 4- 9_.`=L s-- VAC-L— iV-4 }'ri lI <br /> - <br /> Work will commence on or about to y - Ci`-1 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 rule s,' regulation.s 'of San Joaquin County and subject to <br /> inspection and approval. <br /> Si ature of Applicant Title + J' ante <br /> MAST8IYPS\MMS®L (6/00) 1 <br />