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APPLICATION FOR ENCROACRMENT PERMIT <br /> PLEASEPRINT. <br /> Date _ /ow O� OFFICE USE ONLY <br /> To: San Joaquin County JOB #_ REF # <br /> Department of Public Works APN CR # <br /> /__• I EXP. DATE .j•i <br /> C� VALID- //•/7.40 TO .u/ DRIVIMAYS: <br /> ' <br /> (Applicant Name) STREET <br /> '_! `� '7� /N J( ✓• AREA JT' QUAD + <br /> TYPELG ADlE A99 <br /> �i <br /> (Hailing Address) FORMS L <br /> o* NOTE <br /> (Cit'/, State, Zip Code) <br /> -7¢Z - 1,S'64- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> J1C �i 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 /> otherwise- encroach on County Highway Right-of-Way-on-the ,ds7" sift'of <br /> 1.41/S60A&;Jr✓ I0V-f approximately 3$ fee / �'1 74r;;)y <br /> of l��llitJl 6C%/✓� Aoe• Oc by -per€ormin the <br /> following work (description of work) : n/ Q oX. �x � ;-W <br /> Ik 10V a it <br /> Work will commence on or about / for approximately <br /> O Z© 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 /> Signator of Applicant -Title <br /> Date <br /> mkT=.PS\BSBS®L (6/o0) <br /> i <br /> i <br />