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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� 1 -06 <br /> OFFICE USE ONLY <br /> To: San Joaquin Countyyy- - –_ -- <br /> JOB # J�10 REF # --------.�--- <br /> Deepp�(artment of Public Works APN -— CR' # <br /> vl <br /> EXP. - DAT / d <br /> VALID �ewWO TO / jj DRIVEWAYS: <br /> (Applicant Name) STREET <br /> .,ter AREA jg �C.C�T QUAD <br /> ( _ YPE � T1PE UGEI <br /> (Mailing Address) FORMS <br /> 4 NOTE, <br /> Y <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLANv <br /> SHALL BE AS PER C* <br /> d% CURRENT M.U.T.C.D. a L- <br /> CALIFORNIA SUPPLEMENT rc" <br /> cn <br /> / f ] ►m <br /> aY �< <br /> BOZO �7 o <br /> The undersigned hereby applies for permission to excavate, cons ruct and/or <br /> otherwise encroach on County Highway Right-of-Way on the <br /> of 1 --'— approximatel — `id�e of/1��,,, r1 �a�� feet/np�� <br /> foll—ow-fin work (d scr' tion of wor by perfo"minhe <br /> Work will commence on or about �f <br /> days. Y �� for approximately <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 /> It <br /> -',,�nlbf 6J67 <br /> Si ature of Applicant - Title <br /> Date <br /> MAST o \FEESCADL (6/00) K TO. <br /> JOB PROMS DESK- <br /> BLD 1 <br /> �WLaM <br /> CA 95204 <br />