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APPLICATION FOP. ENCROACHMENT PERMIT <br /> PLEASE PRINT:' <br /> Date OFFICE USE ONLY.- <br /> TO: <br /> NLY,.To: San Joaquin.County JOB # /j7r%�1 �D REF # <br /> Department of Public Works A.PN CR # <br /> EXP. DATE -15--•d <br /> VALID• Id-2-&,7. TOs DRIVEWAYS: <br /> (Applicant Name.) STREET <br /> AREA G✓N�En/ QUAD <br /> TYPE A_C�-Zz l/i✓45LV7- <br /> (Mailing Address) FORMS. <br /> / 'NOTE <br /> (City, State, -Zip Code) <br /> (Area Code - Telepho a Number).. <br /> Sketch, (Detailed plans may be• submitted)- <br /> TRAFFIC CONTROL PLAN <br /> 5HALL BE AS-PER <br /> i!r' CURRENT M.U.T.C.D. <br /> G1� CALIFORNIA SUPPLEMENT <br /> The undersigned hereby. applies for permission• to.excavate, .conatruct and/or <br /> otherwise•-encroatth-oa••Cou-ntg-'Highway Right=of-.Way•on.•the ti:L '�"' -: side::•of <br /> Ta�'c izJ;:2 Da L_C- P X-> approximately 8 & feet/tm �o�)rl-t <br /> of L.'i b.tl=�E== • by-pe'rformirig the <br /> following work (description of:work).: ii•iS•Tla LL �12�' PL_ n.,,s. SC- izy1GG <br /> A`t- 4PaG1 •t�RC.N�2t�ALL==. i�i� <br /> li-Adr yA t41-\TNy (AW4� N. <br /> Work will .commence on or about 1U 0 d2_k- for approximately <br /> i 28 <br /> days. <br /> I, the undersignedcertify, that I am the owner of, the respect i.ve,•-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 /> if <br /> �� � -a�- q,•- 2A-ram <br /> Si ature of Applicant - Title Date <br /> `.A <br />