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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -Z- OFFICE USE ONLY <br /> -% <br /> To: San Joaquin County JOB # 75050--(o REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE la-l'e7 <br /> e t VALID 5-/S-y7 TO /d-%d? DRIVEWAYS: <br /> Applicant Name) STREET ( ,� LAI <br /> ,,--..�� p LIeAAREA :�A�A_ QUAD <br /> &cam KE TYPE J?-CLL <br /> (Mailing Address) FORMS <br /> NOTE <br /> 5 <br /> �(City�, ta�te, ip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> -� SHALL BE AS PER <br /> CALRIFORNIA SUPPLEMENT <br /> 0) 5x5 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> o herwise-encroach on County Highway Right-of-Wa - the the St)CAT $ side..of <br /> 4 LEY approx' tely n feet/.fie EAZU <br /> of by "performing the <br /> for work. (d seri tion of ork) : <br /> Plato <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 /> insp io and approval. <br /> ® 4DE7 <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br /> it <br /> i <br />