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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date o I`q /Q� OFFICE USE ONLY <br /> To: San Joaquin County JOB # '43052 - (0 REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE ' <br /> VALID f1 �i�_C�. TO dY DRIVEWAYS: <br /> (Applicant Name) STREET ALtr. SF. <br /> np)j a 4-)n AREA a0cKT0l.-, QUAD <br /> WESC TYPE JKECL. NoL.,E- <br /> (Mailing Address) FORMS ,.i <br /> NOTE <br /> (City, State, Zip Code) <br /> ez <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) a N <br /> TRAFFIC CONTROL PLAR v <br /> SHALL BE AS PER o <br /> CURRENT M.U.T.C.D. -11 ---1 r),.m <br /> CALIFORNIA SUPPLEMF4 ,N L? <br /> a � = nrn <br /> c-n z <br /> PM. b 53ooa 0 " w <br /> o : t 2 'P <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the� side of.1G� approximatel 107 feet/nVAtNDrJ <br /> of { Pv.R, , by erforming the <br /> following work (descripti n of work) : 1 <br /> Work will commence on or about 0 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 /> - I � ir(oD�l'4 <br /> D• <br /> 6 161/0& <br /> T <br /> rature Applicant - Title TDate <br /> (�/00) RETLMN PERMS l O. <br /> • "E <br /> JOB PROCE158i1VQ DESK- BLD 1 <br /> 4040 WAIW Lane <br /> ST'OCKTON, CA 96204 <br />