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APPLICATION FOR ENCROACHMENT PERMIT <� <br /> �fEf' t�j <br /> PLEASE PRINT: `�✓,off✓` ',, f <br /> Date O� OFFICE USE ONLY /� w ` <br /> To: San Joaquin County JOB # <br /> Department of Public Works APN CR # <br /> EXP. DATE d ' <br /> VALID (Q TO d DRIVEWAYS: <br /> (Applicant Name) STREETAo . <br /> AREAkt QU <br /> TYPE ALL rfl7lf if :nft � <br /> (Mailing Address) 4 FORMS _ 29 <br /> ,r� NOTE' <br /> .:,(City, State, Zip Code) <br /> (Area Code - Telephcne 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 /> E'": ea <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> o herwise e roac on C ty Highway Right-of-��W,ay on then side of <br /> .r— a � �+rV T f� .fig <br /> csi[ bMerfrming th <br /> foll in work (descri do of work) : JG� as <br /> Work w'11 commence on or about for approximately <br /> y 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 /> AMON� -"ZA,lb"I C 5. 2"0" -(> <br /> Si .ature of Applicant - Title Date <br /> RETURN PERMITS TO: <br /> MAST P \FEESCIML (6/00) • � <br /> .10B PRMESaING DESK BLD 1 <br /> 4040 Wed Lams <br /> ST�OCKTON, GA 96204 <br />