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APPLICATIOW F,O§AWT &L&"�I aTRMIT <br /> ouY <br /> PLEASE PRINT: 2 SEP 25 AM 9: 05 <br /> Date %-�p( ^:D�/ DEPT 0 PUBLIC IWSCE USE ONLY <br /> To: San Joaquin County JOB g REF 4 <br /> Department of Public Works PIN CR, rt <br /> EXP_ DATE <br /> VALID. `1'5-e,6 TO //1.'t 1J10'S DRIVEWAYS: <br /> (App <br /> �licant Name) STREET <br /> �D 1/0 (/v /!t� AREA SRL' TL�tI QUAD —1 <br /> T`IPE <br /> (Mailing Address) FORMS .957&� , R <br /> NOTE. <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> I _ <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> ' SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> ; CALIFORNIA SUPPLEMENT <br /> �l f <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the A6 side of <br /> Sd/f,�sF7" approximately /G O fee /mile iV1,0 <br /> of 776 Z72 7Z)C- <7^0A1' by performing the <br /> following work-, (description of work) : <br /> Work will commence on or about 1,911106 for approximately <br /> 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 ru];es, regulations of San Joaquin .County and subject to <br /> inspection and approval: <br /> A, -./K9"i-� 61fs 1�o7wotme- <br /> S_yL-at:=a of 'pp11L-cant - Title: Date <br /> ���' RETURN PERMITS.TO: <br /> NASTE3.PS',.FEESCHDL (6/CC) <br /> JOB PROCESS 4G DESK- BLD I <br /> 4040~I M <br /> STOCKrM, CA 952" <br />