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». APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /��2��y� OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 7 3 o S 2- Co REF # <br /> Department of Public Works APN CR # <br /> / - / EXP. DATE <br /> / C -�, b" VALID• TO DRIVEWAYS: <br /> (Applicant Name) STREET SI C fji <br /> 40 0 C��J {J/a/C� AREA STiS CSfd�UAD g S <br /> TYPE �F4.L..HOTSN. <br /> (Mailing Address) FORMS w,✓ -�Y . <br /> NOTE <br /> (City, State, Zip Code) <br /> 05> <br /> (Area Code - Telephone Number) <br /> Sketch ADetailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: �m 3v�319� <br /> J013 PROCE38MV0 DESK- BLD 1 <br /> 4040 VM»t LWW <br /> 6 CM t 1 ON, CSA 95204 <br /> The undersigned hereby applies for permission to.excavate, .construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on-the SJt�l'1� nide..of- <br /> .�. <br /> -52<1-11 677 approximately -4fee t +e �,�/ v`'T <br /> °f �� ;, �� by performing the <br /> following work (description of work) : e ? <br /> rv�� �r�c c1 v 'G � "W •�. X79 sS .ts <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 /> Signature of Applicant - Title to <br /> :PSIS®z s6�oo� '�1 Ol Nd 't- 330 9002 <br /> 03A 303d <br />