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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> To: San Joaquin County <br /> JOB # -7 SO REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE t Z=�'�_p� <br /> VALID In-1 S--©i. TO i I n' DRIVEWAYS: <br /> (Applicant Name) STREET YvIiDSE����J <br /> QUAD A&V <br /> TYPE BE,- Noce <br /> (Mailing Address) FORMS. <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telepho a 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 he.reby applies for permission to.excavate,,"..cons•truct and/or <br /> otherwise-encroach-On County--Highway -Way-.0n.-Right-of the e: ..." `. side._of <br /> A,AL.3/. i lj�- approximate1 r -'= feet/mAi a tbig"1-4 <br /> of .i(hnrn L.tyt � by performing the . <br /> following work (description of: work) : in6 <br /> 9 ryr��rd�.n Mid <br /> Work will commence on or about for approximately <br /> / D 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 /> 14 <br /> Si .ature of Applicant Title :01 W1 S- AVA L 00 Date <br /> MAS PS\FMSCSDL (6/00) <br /> i <br /> i <br />