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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �a, r '� �.., OFFICH USE ONLY <br /> To: San Joaquin County JOB # '-46! Z2- REF # <br /> Department of Public Works . APN CR # <br /> EXP. DATE -I <br /> VALID. io-22- 1. TO DRIVEWAYS: <br /> (Applicant Name.) STREET OC�C_LL .:ASE, <br /> &2A__ <br /> AREA ST6C/_760 QUAD_ TYPE My !n/,>,Cr <br /> (Mailing Address). FORMS. _� <br /> NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telephohe Number) <br /> Sketch (Detailed plans may be submitted) <br /> A'FFIC CONTROL PLAN <br /> SHALL RE AS PER <br /> CURRENT M.U.T.C,D. <br /> CALIFORNIASUPPLEMENT <br /> The undersigned hereby applies for permission- to.excavate, .construct and/or <br /> otherwise-encroach-oiE Connty:Highway. Right-of-Way--on-the �A." ,"S' side:;•of <br /> approximately ib4-� feet <br /> _ <br /> of `rcof—A by "Performing the <br /> following work (description of.- work) : 4,44.. -n - lr4 <br /> �I t3�rAL� hl r����`7 i� .-�Le Gar=b. �-�.v► _ -T�. "�t7��^-�.,fi�r�r-=� <br /> Work will _commence on or about i� - -Z C?-I for approximately <br /> 1'2 L 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, re <br /> gulations "of San Joaquin County and subject to <br /> inspection and approval. <br /> `� <br /> a I C "2 -- <br /> c7� <br /> Si ature of Applicant Title , �)u!. Daae <br /> �•� q,... <br /> MASTB.PS\ S®L (6/00) <br /> '1 <br />