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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ^ 6-0 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7 3[52-- G REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET jqOiQNCIk- A✓E <br /> r <br /> `'�� AREA STKA1 QUAD 6S!/C,r"Jl ZJ1 TYPE L-L HOIE Ti(c�E)7Ci-! <br /> (Mailing Address) FORMS � &44, <br /> �' I(A1>�J `�� � � ,rj��_,•� <br /> 164- NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLA u� <br /> SHALL BE AS PER n <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMEQT M. <br /> =a m <br /> r- � =rn <br /> G <br /> r <br /> C-, = ;T 4 <br /> ��rn <br /> t !o N <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwi e encroach on County Highway Right-of-Way on the �.�l r , id f <br /> approximately Z9 z feet/ <br /> of by erforming the <br /> following work (descri tion of work) : <br /> 6fa'd- AD <br /> 7 <br /> Work Will commence on or about - i -fir for approximately <br /> 00 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 /> Si ature of Applicant Title Date <br /> RETlIF�11 MPE'RMrM TO: <br /> RASTOP '�,FcFS CiDL (G/GO) pp�c • <br /> � <br /> NW r RVC&NM YEW- BW 1 <br /> 4W��/�{/ �j�, <br /> Law <br /> �/ <br /> S•Off,M, CA <br />