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APPLICATION FOR ENCROACEMENT PERMIT <br /> PLEASE PRINT: <br /> A <br /> { <br /> OFFICE USE ONLY <br /> Date <br /> TO: San Joaquin_ County JOB REF '-# <br /> Department of Public Works APN CR <br /> EXP. DATE <br /> VALIDTO DRIVEWAYS: <br /> PGBcE STREET <br /> AREA 5vr .em-1 QUAD <br /> 4040 WEST LANE TYPE TG G <br /> FORMS <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Zip Code) <br /> 611A-2- !621 2? <br /> (Area Code - Telephone Number) <br /> c; <br /> Sketch (Detailed plans may be submitted) TRAFFIC CGN T ROL °!_.SP1 �N <br /> SHALL SE AS PER Y., <br /> CURRENT M.U T C.0 C= -: <br /> CALIFORNIA SUPPLE;#EN- -,0 <br /> SEE ATTACHED SKETCH s <br /> PIVD <br /> NOTIF c x <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ,,". �( "`. <br /> otherwise-encroach on Cour:ty N�.ghway Ri gh t-of-W2 os the �,. <br /> �•. approximate) feet/ e Eside 9f <br /> fi <br /> by per€ormirg the <br /> r— <br /> _folio ing_work idec s t. o of work) <br /> Work will commence on or about F' 1l 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 /> S ature of Applicant - Title Date <br /> �MSTER.as\12-IMs®L (E/oo) RETURN PERMITS TO: <br /> CCD <br /> P&&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />