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APPLICATION FOR ENCROACBMENT PERMIT <br /> PLEASE PRINT: <br /> Date /(ice / (� oFF2CE. usE oNLY <br /> To: San Joaquin County JOB g 730 5Z- CD REF <br /> Depa/rtmien't[of Public Works AN CY it <br /> EAP- DATE <br /> Vr,LID m0 DP.IVEWAYS <br /> (Applicant Name) STREET Srwsc�sarrz f}VEtilo <br /> /j AREA _&t QUAD CC- <br /> Uj O bh( ) �Aa- TYPE "RFS,- 6a.—e 30T-e <br /> (Mailing Address) FORMS S Iu • 2 -Z2 <br /> NOTE T <br /> S— c CV 9 s z)Ci <br /> (City, State, .Zip Code) <br /> 9412-/I& 6 <br /> ' { rea Code - Telephone Number) <br /> Z L0 <br /> a0 SkTetcHa*,(Detailed plans -may be submitted) ' TRAFFIC CONTROL PLAN <br /> c.> <br /> >Z a � SHALL BE AS PER <br /> CC > CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> CX C: W o <br /> C= �- <br /> o <br /> o <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-way on the L---4 S-1�' side of �• � <br /> 51tjC14( K J0 C appro:rimately 7� _ feet/mile 5OL14 h <br /> of L/ 1 Gt �— 5 t�C.l�>L6✓✓►•` by performing the <br /> following work. (description of work) rYCK1t�e� '( sera <br /> q 1 y'�.C�<�Gc�r p it 5- <br /> Work will commence on or about. for approximately <br /> ` U 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 ap oval. <br /> s_yuat-uie RETURN PERMffS.TO: Date <br /> MASTER.PS'--PEESC-ML (6/00) <br /> :SOB PROCESSM DESK-BLD 1 <br /> 4040�YVda#LMW <br /> STOCK X71 CA . <br />