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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73052.-(o REF # <br /> Department of Public Works APN CR # <br /> EXP. _DATE t-L-/-07 ` <br /> VALID 10-28-0(o TO _5-t-0'7 DRIVEWAYS: <br /> (Applicant Name) STREET // T" '5-rA�. <br /> AREA 57-64 A/ QUAD _ <br /> TYPE hot TIQ2 ACI�1 <br /> (Mailing Address) FORMS 55 -Z9 <br /> �`® i o A , � 9 <br /> NOTE- <br /> hi-on , <br /> OTE <br /> W ity, State; Zip Code) <br /> Ae2 IC�2� <br /> U iArea Code - Telephone Number) <br /> . i&tov (D-tailed plans may be submitted) <br /> �- TRAFFIC CONTROL PLAN <br /> C..) SHALL BE AS PER <br /> C= a CURRENT M.U.T.C.D. <br /> LR. `'" o CALIFORNIA SUPPLEMENT <br /> o : taZZ -t <br /> The undersigned hereby applies for permission to excavate,, construct and/or <br /> of erwise�encroa h on County Highway Right-of-Way on the side of <br /> approximatel feet/ <br /> Of by perfor ing the <br /> followin work_. (description of work) :, <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 /> ►bT C 67 tim r IC-41-7 <br /> Si ature of Applicant - Title to <br /> RETURN PERMITS TO: <br /> f9A5T .P \FEESCHDL (0/00) ��j� Pam <br /> Q �� �y <br /> JOB P ■ O Ma..M DES/ - 6LD 1 <br /> 4"0 fta Lane <br /> ON CA <br />