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APPLICATION FOR FNCROAC CKNT PERMIT <br /> PLEASE PRINT <br /> Date r" l . � OFFICE USE ONLY <br /> To: San Joaquin County JOB # 754?!��__(0 REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DATE _-2 <br /> C t VALID 9/S3 TO •,•O DRIVEWAYS: <br /> (Applicant Name) STREET MIJt 4 ALS . <br /> AREA QUAD _ <br /> TYPE ..x�CG <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, S ate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 5 ! l -�'A�D E'.'�_�G� SHALL BE AS PER <br /> ,. . � CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otrwi e enchAtleunty Highway Right-of-Wa s the .St�c.e side.of <br /> F-Zapproximatel ! feet _ <br /> of by "performing the <br /> fol wing wor�k� scr1::>j L4 wo �5 r <br /> r <br /> Work will commence on or about D for approximately <br /> Q <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 /> Zlo3-nsand approval. <br /> � s -ADP__ �� f <br /> Signature of Applicant - Title Date <br /> W_SM.PS\FESS®L (6/00) <br /> i <br />