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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date tVILr Z OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> / <br /> EXP. DATE �1' �' 07 <br /> L�, 4►-- , <br /> Lot t VALID - 45-0TO f7-/-a7 DRIVEWAYS: <br /> (Applicant Name) STREET tDC�,eTHu� �• <br /> AREA -77-wcy QUAD SLJ <br /> tl�F-4�rr_ 0 . TYPE .%GGG <br /> (Mailing Address) FORMS :g5 hyLU; <br /> NOTE <br /> (City, State, 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 /> CALIFORNIA SUPPLEMENT <br /> 4L)(G� f5a <br /> The undersigned hereby applies for permission to.excavate, .cnstruct and/or <br /> otherwise-encroach on County Highway Right-of-Wa -oa-(t]�ie side.-of <br /> e, ED approximately feet/m=a __SQc_1 <br /> of by performing the <br /> following work (description of wor ) <br /> �?,5 EA&A:5 <br /> Wor will commence on or about M AR C��'� 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 tion and approval. <br /> A�r 'Z ZD0� <br /> Signa. Title Dat <br /> MASTER.PS\FEES®L (6/00) <br /> I <br />