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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:V1 (� <br /> Date Nov.V. —l� Zoog OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 23 09 TO lS D _ DRIVEWAYS: <br /> A G. &E. CO. STREET We'A6A'eD en _ <br /> AREA QUAD A-- ` <br /> 4040 WEST J�ANE TYPE 5, <, <br /> STOCKTON, CA 95204 FORMS 5 wiv, <br /> NOTES <br /> ( rea Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM 4-i Z 0-7 '7gg current M.U.T.C.D. i <br /> Notif. p36( 7` Z�d California supplement. i <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the A A5T side of !-Vubbaav-ii 12-d. approximately S(,o l feet/n Ito 2tt{ <br /> of C4.1�Vi�IC�2� 1 s�r� by performing the following work(description of work): <br /> 14 L <br /> Work will commence on or about !t for approximately days. <br /> I,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 /> Signature to plicant-Title ate <br /> o5'r. +aa5 �►'ne,en'�� ��i�vca.�c1Y <br /> E1PUB-SVAQMtStVLP ENCROACHMENiP APPUCA710N. M <br />