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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date P.* <br /> 1�7' � OFFICE USE ONLY <br /> To: San Joaquin County JOB # ?'30 sZ -S REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID /0-16-c;M TO 01f-IS-02 DRIVEWAYS: <br /> (Applicant Name) STREET'F S14c€bT * <br /> n� Q rhe AREA STOCAToM QUAD SS <br /> T WO7- WAST- M TYPE L.L <br /> (Mailing Address) FORMS ep &W , Q-27 <br /> �j.�/ j,✓ j�,•.,� ' � Q�s� NOTE <br /> (City, State, Zip Code) <br /> (.Wearode - Telephone Number) <br /> lf <br /> 1st C? <br /> tchQ(D&-ailed plans may be submitted) <br /> C \ 50 <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> C 0 CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, const uct and/or <br /> ottlerwise encroach on County Highway Right-of-Way on the side of <br /> approximate) _ feet/nom <br /> of 1— perform <br /> 'ng the <br /> f llaing work (de iption of work) : <br /> Work will commence on or about to- 140 'fes(, for approximately <br /> —162 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 /> Am a&W - I bf 6k 66* <br /> Si ature of Applicant - Title Date <br /> hlfisT FEEscF (aiGG) C M TO. <br /> ON,STOMTCA 95204 <br />