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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t9 . -1 -O<�-' OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73US�Z �� REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS <br /> (Applicant Name) STREET L� <br /> AREA QUAD �S <br /> TYPE -JCI o E iF _e>or2 * <br /> (Mailing Address) FORMS UA ewl �'Znt <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLA4 o <br /> SHALL BE AS PER �' CA <br /> CURRENT M.U.T.C.D. ^' <br /> CALIFORNIA SUPPLEMENT _ crn <br /> a � C.) _ �m <br /> O �' s <br /> 1 �o <br /> IoZeA-1-764 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the �QatP " side of <br /> 01-0 Ve. approximately feet/; 3 t"lo^-14-N <br /> ofby performing the <br /> f llowing work_ de cript ion of w rk) : <br /> O � <br /> Work will commence on or about for approximately <br /> ltl�o 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 /> Si ature of Applicant - Title Date <br /> _ PERWM TO: <br /> FIAST .F \FEES CTO7L (6/00) pm PCG <br /> prM <br /> JM r /GSSM DESK- BW 1 - <br /> 4040,~UM <br /> STOCKMN, CA <br />