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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> /L (3 _Zpp� OPTICE USE ONLY <br /> Date <br /> JOB # Z C� " REF # <br /> To: San Joaquin County CR # <br /> Department of Public Works APN <br /> f. EXP. DATE <br /> ?61 y E CO VALID _ ____ TO ----- DRIVEWAYS: <br /> (Applicant Name) <br /> STREET :!I� <br /> AREA i 6D( QUAD <br /> TYPE T>s - ae e <br /> (Mailing Address) FORMS <br /> NOTE <br /> 5'Co C�Tpr1 f_A �SZc�� <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 /> otherwise encroach on Count-y--Highway Right-of-Way onthe EA side-of <br /> a roximatel ee /mile SnuT� <br /> Pp y � <br /> of �42by"performing the <br /> ' <br /> following work (description of work) : 4i p <br /> e.AX, �aJ ►�vQ--nom of Jacac <br /> SC-17_4 v Ta S ER-VCF_ lSAGK <br /> Qobt� 3a <br /> Work will commence n or about V fL- for approximately <br /> o <br /> Z 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 /> -07 <br /> t 0 :01 WV S 1 S3J L001 Date <br /> Signature of Applicant Title - - . <br /> MASTSR.PS\FBBS®L (6/00) <br /> l re13"D3 <br />