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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEAS PRINT- <br /> Date �Q/��cX Do G� OFFICE. USE ONDY <br /> T o: Saxi Joaquin County � jOi5 � �./VSZ^� RE F ;F <br /> Department of Public worl-S <vN CR # <br /> ,tom <br /> EXP_ DATE S-1-01 <br /> e/9"S 4' C `% /e VALID 11-10-oco TO 3-1.01 DRIVEWAYS: <br /> (Applicant Name) STREET llbdD'RQJDr� Rb. <br /> _ AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, Slate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sk% :h Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> w <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on Co}}Y Highway Right-of-Way on the _�O U T/� s;de f <br /> /� approximately / / ee mile /� <br /> of lc 4zeeeojstO 724 l4dk-S LOIS / by performing the <br /> ollowing wcrk (description of work) : <br /> - <br /> �D / 6e 26P5 A16 <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 subject to <br /> inspection and approval: <br /> Sig--at-,=e Of pp-11cait - T-tie Date <br /> RETURN PPERMfTS TO: <br /> r-TER.PS•.Fees(-_-M)L a/co) PGM <br /> PROCESEUM [*SK-BW 7 <br /> 4040~ <br /> , CJS►962m <br />