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¢ e <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date —6 - �O OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7.305Z'(,a REF # <br /> Department of Public Works APN CR' # <br /> f � � <br /> EXP. DA/�T 2 L <br /> (� VALID B TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 51MA QUAD rS <br /> ` (�J TYPE GL ROZ4, 6.602E <br /> (Mailing Address) O4 FORMS <br /> NOTE <br /> (City, State, Zip Code) <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. rn o <br /> CALIFORNIA 5UPPLEMMT'=%, <br /> r �{ <br /> �v <br /> i �o IDZc��'1 X. <br /> The undersigned hereby applies for permission to excavate, const uct and/or <br /> oth( w,Iise encroach on County Highway Right-of-Way on the side of <br /> --..�1 1a r k+e► approximately feet/(aj:kp_ ='h <br /> of ('.'. r` 1 by performing the <br /> followin work (descripticn of work) : <br /> Work will commence on or about for approximately <br /> I— 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 /> bIr �6? <br /> f 10 a` <br /> ISiature of Applicant - Title Date <br /> FEES=L (e/00) PERWM TO: <br /> P <br /> 4040 VAM Lw* <br /> STOi+RON, CA <br />