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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date 1 ' OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7REF # <br /> Department of Public Works APN R' # <br /> EXP. DAT' / <br /> VALID f DRIVEWAYS: <br /> (Applicant Name) STREET 1� Eyl <br /> I�� `'W�� AREA ST�G.�To4)QUAD :ES <br /> !� <br /> 6049A E TYPE 1�4CG DLE TiQEtI.L' f1 <br /> (Mailing Address) FORMS -�li� < <br /> 61'G6-hien , lC NOTE <br /> (City, State, Zip Code) <br /> XI d2 - 162 <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 /> r r' <br /> � N <br /> Q 4 0 <br /> The undersigned hereby applies for permission to excavate, construct andMr <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately feet/ 19 6MA442, _ <br /> of , 11 by perform'ng the <br /> fo110 in wor (description f work) (� tl <br /> Work will commence on or about for approximately <br /> Lbo 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 /> 06, <br /> Si,tAST .P <br /> ure of Applicant - Title �� Date <br /> ' FEESCfQ)L (6/00) " KRWM !O: <br /> • VEL <br /> •�Oe PROCE $INCi•tam - ow 1 <br /> *X0 V14t <br /> 3TOCKTOKCA 95244 <br />