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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date '�� OFFICE USE ONLY <br /> To: San Joaquin County JOB # �� /a REF # <br /> Department of Public Works APN ICREXP # <br /> VALID <br /> / S <br /> VALID T� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA /GAl QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, zip Code) <br /> 16&J <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 /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> oth rwise encroach on County Highway Right-of-Way on the , side of <br /> approximately --15 z feet/rzt�m-- hlQc4in — <br /> ofsag V�� I I -)/V'47�-� by performing the <br /> ,tee , <br /> follow.inWork (description of work : <br /> Work will commence on or about for approximately <br /> te�-et;' 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 /> �Vw 9001 <br /> Si ature of Applicant - Title Date <br /> H ( <br /> RETURN PERMITS TO: til 3 A 130 <br /> t1AST _ FEESCHDL 03/00) • � <br /> efOB <br /> PROMSSM DESK- BLD 9 <br /> 4040 West LWW <br /> 3T OCKTON, 1 A 95204 <br />