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L <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date A <br /> OFFICE USE ONLY <br /> To: San Joaquin County -- --- <br /> JOB # REF # <br /> --.- <br /> Department of Public Works APN <br /> CR # <br /> EXP. DATE / <br /> VALID S TO // /fid <br /> (Applicant Name) STREET �i9�alrY DRIVEWAYS: <br /> 9�D �IC7 //ll AREA QUAD <br /> TYPE 7;>,o <br /> (Mailing Address) FORMS <br /> 1 �d NOTE, <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> (Z421�) eZ - 6P <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> pm: 3o4qtj!ZZ <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> other ise encroach on County Highway RightIon <br /> on the1 side of <br /> approximately _ feet/� ��. <br /> o f <br /> following work (de cription of work by performing the <br /> Work will commence on or about <br /> days. � for approximately <br /> I, the undersigned certify that I am the owner of the respective propert a <br /> qualified to represent the owner and agree to do the work , <br /> accordance with the rules, regulations of San Joaquin Counttysandbsubjeed ct'to '-r?" <br /> inspection and approval. ? <br /> Na <br /> 00 =i <br /> rrl <br /> Sitature of Applicant - Title W ` ' <br /> T62 r <br /> Datac <br /> hIAS ,PEESCE�L (6/00) RE1 LMN PERWS •V: n? <br /> •SOB PROMS DESK- BLD 1 <br /> 4"0"W LWW <br /> $TOCKMN,CA 95204 <br />