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9 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date // OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> /� EXP. DATE <br /> P <br /> � VALID 9-f 07 TO 1-/5--,07 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> " ( TYPE _e6'66- <br /> (Mailing <br /> Po,k✓ -(Mailing Address) FORMS <br /> NOTE <br /> L'2(4 <br /> (City, State, Zip Cod-, <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> )(%, <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise e�jcroach .County Highway Right-of-Way,on-the side.of <br /> 22 approximately �7 eet/ ile -C�'_�r <br /> T- <br /> of L--rl2c e_77? I . y -performing thp <br /> following work (description of work) : �Jdi_N_. L/ r>-�� � U�� Ce-;,7- <br /> Work <br /> %2Work will commence On or about for approximately <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 /> ' 1 <br /> l <br /> Signature of Applicant - Title Date <br /> 8S :6 A R 6VW 1002 <br /> MASTHR.PS\nHS®L (6/00) <br /> .- <br />