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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: f <br /> ! -7 <br /> OFFICE USE ONLY <br /> Date r <br /> TO: San Joaquin County JOB # 3� �2 - REF # <br /> Department of Public Works <br /> APN CR' # <br /> EXP. DATE <br /> _ VALID TO cv DRIVEWAYS <br /> STREET 7 -,.,u���[�/�_ A�/&, _ *c`�= ---- <br /> (Applicant Name) . *_, <br /> AREA SToeA7a'! QUAD NS <br /> <� �rt�iyoul.E T,Q Nuf C_ *9'�%��(% ��/P /P,/✓v- TYPE y..._ — <br /> (Mailing Address) FORMS 552- /./cJ <br /> �.y NOTE a <br /> (City, State, Zip 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 SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> -moi, side_of <br /> otherwise- encroach on County Highway Right-of-Way oa the - <br /> approximately <br /> of �c/.f.✓.T>� �� ✓ by per€ormirig the <br /> following work (description of,work) : <br /> J. <br /> Work will commence on or about r' '� <br /> ��,' iJ for approximately <br /> c7 <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 Qapproval. <br /> Signature of Applicant - Title ate <br /> MASTER.PS\FRES®L (6/00) <br /> it <br />