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m <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 10- (-CD <br /> VALID S-2.':;-- TO 10-1 -0-) DRIVEWAYS: <br /> (Applicant Name) STREET <br /> � AREA -9;i-6--kC0 Q QUAD '5F <br /> "EL- : L/&AE TYPE'_?�C--LxKc1 _ 't7_9-CLX(-4(-4 <br /> (Mailing Address) <br /> FORMSWvU � <br /> �^- NOTE <br /> J 8� <br /> (City, s -ate, Zip Code) <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 /> 6 CALIFORNIA SUPPLEMENT <br /> x ��4 ?E"cTt <br /> The undersigned hereby applies for permission to.excavate, n.s�truct and/or <br /> otherwise encroach n Count ghway Right-of-Wa Qo -t a OH e.of <br /> BO approximate�ly__ feet/ si e5 <br /> of by -performing the <br /> following work (description of work) <br /> ZEEL -6-e Vi=a f <br /> 1EtLy—AlTa VAU105 aLJ. – O — A-F_ d-rLiz <br /> Work will commence on or about M AY 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 /> ins n and approval. <br /> a, <br /> Signature of App icant - Title Dat <br /> MAST%R.PS\MSCSDL (6/00) <br /> I <br />