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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date Z � OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7� -( REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID OZ-eSF-d T -ell-107 DRIVEWAYS: <br /> (Applicant Name) STREET B, z <br /> "C�✓ � ��� �N� AREA Fife wcN CAM�UAD E <br /> TYPE LL NODE $04E <br /> (Mailing Address) FORMS UXa), o-Z9 <br /> CA NOTE <br /> (-City,S te, Zip Code) <br /> (Area Code - Telephone Number) <br /> SketchUU3Detiled plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> 0 CALIFORNIA SUPPLEMENT <br /> ter, <br /> c <br /> N :.t1 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the side..of <br /> upc�O-Dgz:r '1�i-T�> approximately (f(ie�/mile 'C <br /> of w�Dr.S pg� , by-performing the <br /> following work (description of work) : i — i � C- k N ._ <br /> Z. i ✓ c c A - � ' <br /> Work will commence on or about 1- C—AP y for approximately <br /> �- <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 approval. <br /> Signature of Applicant - Title Date <br /> MASTSR.PS\FABS®L (6/00) - <br />