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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- <br /> Date L <br /> OFFICE USE ONLY <br /> To- San Joaquin County JOE REF <br /> D artment of Public Works APN CR- <br /> EXP_ DAT IZ ! d <br /> VALID 7 3! Oro TO Z / DRIVEWAYS: <br /> (Applicant Name) STREET B✓' <br /> O <br /> AREA 4 QIIAD SE <br /> L01 TYPE Gam! e 461+Q _ <br /> (Mailing P_dd-es s) FORMS <br /> NOTE <br /> (City, Sta e, Zi- Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLAMEW u' <br /> C_CD <br /> z OM <br /> .. t . <br /> The undersigned hereby applies for permission to excavate, c nstruct y*hd/ ' <br /> ot,4erwise ncroach on County Highway Right-of-Way onthecn si e of;, <br /> approximat y feet/fie <br /> of by performing phe <br /> €o lowingwp k (descri o� o work) : <br /> Work will commence on or about d for approximately <br /> _ 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 /> -grat-uia Of f.r icant - a :ate <br /> RETURN PERMITS.TO: <br /> HFSTE2.pS••,FEESC-ID?, !6�pO) r�& <br /> :,JOB PRO,�C//��E`�//3�� <br /> *MOW" <br /> - BLD 1 <br /> */ 7 " LA CY <br /> STCCK7DN, CA <br />