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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date v l� G 7ZOFFICE USE ONLY <br /> REF# 3b 5 2- (d # <br /> To: San Joaquin County JOB CR # <br /> Depar. nt of Public Works APN <br /> - <br /> EXP. DATE <br /> VALID 0`- 4-- TO D`/-3o-O 2 DRIVEWAYS: <br /> (Appl - ant Name) <br /> STREET ( A605,f�liV X042 5 <br /> AREA ��Ay QUAD J <br /> TYPE <br /> (Mailing Address) <br /> FORMS w <br /> -NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> J e- mi l SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to .excavate, con truct and/or <br /> rwa.se-encroach �ty--Highway Right-of-Way on�theside ofapproximately cid feet/mileof /l/' _ by yper€o ing the <br /> followin work (description of work) <br /> <51 <br /> i <br /> Work will commence n or about for approximately <br /> o <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 /> 7 <br /> Signature of Applicant - Title LS :6 WV ZZ 83J LOOZ Date <br /> MASTER.PS\FEES®L (6/00) •.E-a! ..` i`'� 'U J ` r \ <br /> 03A13` -i <br />