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APPLICATION FOR ENCROACHMENTT PERMIT <br /> PLEASE PRINT: <br /> r <br /> Date Lr OFFICE. USE ONLY <br /> To. San Joaquin County JOE REF 4 <br /> Department of Public .Works FN CP" n <br /> ESP. DiA <br /> G / 1 VALID �'S a6, TO CO DRIVEWAYS <br /> (Applicant Name) STREET <br /> TYPE STAAKu QUAD �S <br /> TYPE jAoLE F "i"tENctl <br /> (Mailing A-ddress) FORMS <br /> NOTE <br /> (City, State, ZipCode) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed puns may submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> Arl-A0.4, 7:SsergAA <br /> The�undersigned'hereby applies fbr permission to excavate, construct and/or <br /> or,n erwise encr ach on County Hicrhway Right-of-Wa- on the side o <br /> LIiJ'fezen o9mg. 44"z 6uEPJV <br /> of by erformthe <br /> followin work (descri tion work) : <br /> r- <br /> Work will commence on or about 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 rules, regulations of San Joaquin .County and.subje.ct to <br /> ins on and ap oval: <br /> —.�at-��a of ApN -cant - Title Date <br /> S y <br /> RETURN PERMITS TO: <br /> MASTER.PS,'r EESCML 0„/G07 <br /> JOB PROCESS04G DESK-BLD 1 <br /> 4040 West Lane <br /> STOC i�+1C1'� , CA�95204 <br />