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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /L7�.P OFFICE USE ONLY <br /> To: San Joaquin County JOB # ?305Z - S REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID /CG-4-CC TO 0'/-/f-02 DRIVEWAYS: <br /> (Applicant Name) STREET S+44i5TA AV -►�U� <br /> r ,t 1 r t' AREA -,Toc.k-rolu QUAD J F5r L lu TYPE <br /> -0iELLlFolc <br /> (Mailing <br /> s) CD tf <br /> ling Address) , FORMS �✓sJ ,E'-$9 <br /> n r `510 NOTE <br /> , D <br /> (City, State, Zip Code) <br /> '61 <br /> te. (j%.eat ode - Telephone Number) <br /> UJ t; <br /> U - <br /> Q$ tcYj,,,',(De&ailed plans may be submitted) <br /> UJ a. <br /> TRAFFIC CONTROL PLAN <br /> acc. cam,, o SHALL BE AS PER <br /> a CURRENT M.U.T.C.D. <br /> ' C= 0- CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, �st- ruct and/or <br /> of rwis en roach on County Highway Right-of-Wayon the !� side of <br /> approximately 02E5 feet/ra= <br /> of Liffby perforrp-ing the <br /> followi wok ( escription of work) : <br /> . <br /> Work willcommence on or about for approximately <br /> 18_ 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 /> n DCo <br /> raturef Applicant - Title Date <br /> (6j GG) RET <br /> -"""- C PERWM �. <br /> • "E <br /> JOB PPMESSM DESK- SM 1 <br /> STOMTON, CA <br />