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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date _ � � OFFICE USE ONLY <br /> To: San Joaquin County JOB # 70���� REF # <br /> Department of Public Works APNCR # <br /> EXP. DATE <br /> rl_'A A VALID - TO /2 1-� DRIVEWAYS <br /> (Applicant Name) STREET `� <br /> AREA —��<,k—Z/JOUAD f-�S <br /> U•�� TYPE fes` cG(Mailing Address)Address) FORMS <br /> F, <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> �►%� CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to .excavate, f s;truct and/or <br /> otherwise-encroac on County Highway Right-of-W y on-the �' <br /> s'de.of <br /> approximatel feet/ be W04t) <br /> " <br /> of ✓ 3 by performing the <br /> following work (description owork) : <br /> Work will� commence on or about for approximately <br /> 1[.ISZ — dad's <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 /> Sign ure of Applicant - Title £� ;��► '� �1" �+ D to <br /> MASTER.PS\.SCHDL (6/00) i f i <br /> / QQ <br />