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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � 5� -7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # - _-Co REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE i'0 <br /> VALID 47-2-1"0-7 TO _?-1-67 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> /t / r AREA �'t"I<-IJ QUAD <br /> �Qe <br /> e,S! TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> K,q , <br /> ( ity, State, Zip Code) <br /> Zoe z�rs'� <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PEP <br /> /0 L �gU C�� CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RE L)M PERM TO: <br /> J06 PROCESS" DeSK BLD <br /> 4o4o wry <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way-on-the :UC ST side_of - <br /> tA, cPte' yQ Rte„ approximately O e /=-i � ,4L�2e2l_, J <br /> of Z sU c onJ' by "performing the <br /> following work ( escription of work) : or✓e y! dX <br /> sb S ✓G• fa a- mew c e %✓ <br /> Work will commence on or. about Z/ U7 for approximately <br /> X00 <br /> days. <br /> I, the undersigned certify that I am the owner of the re spective, property, or am <br /> qualified .to represent theowner 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 /> Signature of Applicant - Title 09 :01 Wd dUdV UR Date <br /> MASTER.PS\PEES®L (6/00) <br /> 1 <br />