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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # f 3 J`�c."� REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE -o-7 <br /> c VALID Q l=0? TO DRIVEWAYS: <br /> (Applicant Name) STREET GZ*�ItL Ales'- <br /> AREA QUAD <br /> dcC> ( L TYPE "*�!t Nom f f e')e <br /> (Mailing Address) FORMS 5S�w*� ' L� <br /> NOTE <br /> (Citj , 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 /> M acv -11 Z <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encro ch on County Highway Right-of-Way-on-the t;,f-' - side—of <br /> r;rD _ P�Mekj�2z, approximately 5'i A-r �feetmile"per€ormixig the <br /> Of <br /> following work (descriptionof work) : SA�Js� <br /> k ' <br /> work will commence on or about for approximately <br /> 2 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 /> fan -c <br /> gnature of Applicant - Title 3 1 :01 KV C ! 8VW [DOZ Date <br /> S <br /> MASTM.PS\FESSCEDL (6/00) <br />