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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date OgFICS IISS ONLY <br /> To: San Joaquin County JOB # 430 5Z -Cp REF # <br /> Department of Public Works APN CR ., # <br /> r C EXP. DATEO <br /> VALID•0-11-pG ' TO a� O DRIVEWAYS.- <br /> (Applicant Name) STREET 8h T <br /> `T�4}-U �,!/�3TC, AREA STc&YTox! QUAD SS <br /> TYPE <br /> (Mailing Address) FORMS �k/s./ � 7' <br /> NOTE C, rn :o <br /> (ciey, State, .Zip code) T <br /> ( ea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> r/ SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. <br /> RETURN PERMfTS TO: CALIFORNIA SUPPLEMENT <br /> WMESM416 DESK- BLD 1 <br /> ST�OigCTON� CA 96204 <br /> The undersigned hereby applies for permission to.excavate, .construct and/or <br /> otherwiee�-e"�roach on CountyIlighway Right-of-Wa -on-they { -of <br /> approximateside. <br /> ly fee Q -of <br /> n/ <br /> following work (description of work) : -�- . by per€ormjng the <br /> Cc U/�s .�L X! _.�� / +� / LZ CsX. 'X' !, /C 2,- - <br /> s.Ca J✓ i✓� �� - �✓ G 17 Q ' o AJC_r S ;07o <br /> Work will commence on or about <br /> �!ddays. for approximately <br /> I, the undersigned certify that I am the owner of the respectiveproperty <br /> qualified to represent the owner and agree to do the workdescribedabove,inr am <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature�OfAp�plican����� /2 <br /> Date <br /> K+STRR.PS\FSBS®L (6/00) <br /> i <br />