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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT, <br /> Date l `3 U r OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID 5--mss-OTO !o-/5--07 DRIVEWAYS: <br /> (A lie Name) STREET Goohm)A <br /> AREA 1H Cfl,(( QUAD <br /> TYPE 4 L 1-GGE <br /> (Mailing Address) FORMSry Z17 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) , <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 3S� p� 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 County Highway Right-of-Way-ora-the side.of <br /> � <br /> a�' � approximately _/'3' feet/mile <br /> by "performing the <br /> following work (description of, work) ��-� /�Cl�/'01� ��/ <br /> Work 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 /> Signature of Applicant Title A �VW (UOZ Date <br /> MASTER.PS\FESS®L (6/00) - <br /> r <br />