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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date 5c> '' Set--,-7 OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> _ <br /> EXP. DATE <br /> VALID 0-15-0 TO 03'!S-t��1 DRIVEWAYS: <br /> (Applicant Name) STREET rla�►Etz ST. <br /> AREA 5MC. t-aA! QUAD Aaw <br /> _ O V, 1�;v LAY 3 TYPE -19646 !4046 # 16046 <br /> (Mailing Address) FORMS 5—p Z9 <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. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County.-Highway Right-of-Way-ori-the CA_ side of <br /> approximately ee /mile . <br /> of 1=�2�Y �� • a°� �"t'C�C , by "performing the <br /> following work (description of,work) : 5xti-)(,41 <br /> ��. 2T f1'2� s Tl�Ft Ia ( ►JW ad.� 1+0 t—lE-C— - <br /> Y=�Z. <br /> Work will commence on or about "\CZfor approximately <br /> —7 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 /> Signature of Applicant TitleSD ;01 WV _ 63J L061 Date <br /> MASTHR.PS\EBBS®L (6/00) <br /> I <br />