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APPLICATION FOR ENCROACHMENT PERMIT c ,EIYED <br /> a F <br /> PLEASE PRINT: <br /> 2046 MAY I <br /> Cly OFFICE ONLY <br /> Date 6WT. F. PLj�'LIC WC)R CS <br /> To: San Joaquin County JOB # JAL u REF # <br /> Department of Public Works APN CR' # <br /> EXP. -DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET i �f <br /> �f AREA S"l-s�hi' QUAD SJ <br /> TYPE <br /> (Mailing Address) FORMS <br /> (���� , � IC�(�•�t NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> YRAFFIC CONTROL PLAN <br /> ' � ,A`y7f��/,✓< �� � � ` ' SHALL BE A5 PER <br /> : T .D.CURREN`f M.U. C <br /> . <br /> CALIFORNIA SUPPLEMENT <br /> t4qfjr-14A<0 <br /> k <br /> The undersigned hereby applies for permission to excavate _ 't and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximatel feet/ .' le cr- <br /> of '�L by performing the <br /> follow ing work. (description of work) : <br /> Work will commence on or about = - for approximately. <br /> days . _ <br /> I, the undersigned certify that I am the owner; of.._4he )respective pr Perty •s.br ate.: , <br /> r <br /> qualified to represent the owner and agree to do the work desgribedj•above in <br /> accordance with the rules, regulations of San Jo i our'r#U,Wid st <br /> inspection and approval . <br /> - ,�b� � imah� �? <br /> Si ature of Applicant - Title Date <br /> TMST ? `.,FEESC'r07L (6/00) RETURN PERMITS TO: <br /> • GAE� <br /> .109 PROMSSM DESK- BLD 1 <br /> 4040'Wink LW* <br /> STOCKTON, CA 95204 <br />