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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date d Q V . 6. �zwq OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID /! $.09 TO DRIVEWAYS: <br /> AG. &E. CO. STREET 7.- <br /> AREA <br /> :AREA G40op,,!fei QUAD Wj,�L) <br /> 4040 TEST LANE TYPE <br /> STOCKTON, CA 95204 FORMS w <br /> NOTES <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM 307current M.U.T.C.D. i <br /> Notif. l 0 3q 1 50t 301California supplement. <br /> The undersigned hereby applies-for permission to excavate, construct and/or otherwise encroac on County Hi ay Right-of-Way on <br /> the l!t)C�'t side of — approximately_c feet/rr MOP--T+4 <br /> of Dl x by performing the following work(description of work): <br /> Y <br /> Work will commence on or about for approximately days. <br /> 1,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval.. <br /> t:-S. fir. C az, it Z o <br /> Signature of Applicant-Title Q to <br /> EVPU9-SV.WK,MASFRPSIENCROACHMENTPE,MT7APPUCA:RQN.CCC @1104 <br />