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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> OFFICE USE ONLY <br /> Date <br /> # �r't� - REF <br /> JOB # <br /> To : San Joaquin County JOB <br /> Department of Public Works <br /> c� <br /> EXP. DATE ;Z---- <br /> 'l VALID EI!-/y-O TO DRIVEWAYS: <br /> Gk <br /> Name) STREET <br /> (Applicant AREALOT�I QUAD AXk1 <br /> VJ TYPE �3vzCL ftsLE B � <br /> (Mailing Address) FORMS <br /> Q NOTE <br /> 12 <br /> �-�-- i <br /> (City, tate, 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_� <br /> CALIFORNIA sUPPI�EMMT . <br /> c rTt <br /> M, <br /> The undersigned hereby applies for permission to .excava.te, construct:and4r <br /> otherwise- encroach on County Highway Right-of-Way-on-the ee • At mile Wside.o.of <br /> of <br /> approximately <br /> Of d L,�1J LoD� [' by performing the <br /> following work (description of work) TUL <br /> 3054 t to <br /> p� ��p�,`Y for approximately <br /> Work will commence on or about CJD r--- <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 /> © /1D� Z - <br /> {o -o-7 <br /> Si ature of Applicant - Title Date <br /> MASTSR.PS\FESS®L (6/001 <br />