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APPLICATION FOR ENCROACFIIKENT PERMIT <br /> PLEASE PRINT: <br /> Date30 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB #_7'30!5 2 to REF # <br /> Department of Public Works APN CR , # <br /> r � <br /> EXP. DATE <br /> V VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET 'SC.zisTa� AVENUE <br /> AREA `eroc.K 2 QUAD _GC._ <br /> TYPE <br /> (Mailing Address) FORMS SS/�✓a1 R-29 <br /> Ude) NOTE <br /> (Cit , State, Zip Co <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> RETURN PERMITS TO: CALIFORNIA SUPPLEMENT <br /> PGM <br /> (OB PROCE38NJCi DESK- BLD 1' Af <br /> MEMO~Lary <br /> 810 OKI ON, CA 96204 <br /> The undersigned hereby applies for permission to.excavate, c nst ct and/or <br /> otherwise ncroacl on County�Highway Right-of-Way ox-th� <br /> 133. <br /> approximately (�2) fee tri-Ie S <br /> of �ve <br /> following work (description of work) : by pe'rformi j g the <br /> Work will commence on or about /� <br /> ��/' for approximatel <br /> _ days. y <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 /> .16,77 <br /> Signature of Applicant - Title ate <br /> 01 :01 NV 1 - 3309 01 <br /> NASTn-PS\FS85®L (6/00) . <br /> GJ.J.1C1 <br /> JJA1 <br /> - I <br /> i <br />