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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT•j5_0 <br /> Date I !p OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7305Z-1C,�, REF # <br /> Department of Public Works APN CR # <br /> EXP. _DATE 1 .67 <br /> VALID 10--3o-6co TO / ,a DRIVEWAYS: <br /> (Applicant Name) STREET daZe c <br /> AREA aseff /ills <br /> TYPE Wil/ He% sit' Bow <br /> (Mailing Address) FORMS ;S 44? lQ�Z9 <br /> Fid <br /> 44 -�---T <br /> ��j! 'i pn , 1 2 NOTE' <br /> (City, State, Zip Code) <br /> pW _Lh1re* Code - Telephone Number) <br /> tc (D;tailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> CYN SHALL BE A5 PER <br /> �- a- CURRENT M.U.T.C.D. <br /> ' © CALIFORNIA SUPPLEMENT <br /> .; N CL <br /> � �_5 I� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> othXis-et encroach County Highway Right-of-Way on the _ ide of <br /> Q n U approximately D feet/fie <br /> of , by performing the <br /> following work (description of work) : 11 ID lo 1 61 L <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 approval. <br /> k6tnt (/�62 6tlmahr <br /> raturef Applicant - Title Date <br /> (5/00) �RETLMN KRM •�+TO: <br /> • Vii` <br /> `pB PROMSSM DESK-BLD 1 <br /> 4040 Wleg Um-w <br /> STOCKMN. CA 96204 <br />