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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT, <br /> Date J r OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> Co <br /> EXP. DATE <br /> - e0,-J-0_? <br /> ( k'C, CUA rVe�VkO VALID e,-(-o_? TO -/<-Oy DRIVEWAYS: <br /> (Applicant Name) STREET 7_ZAUCAAJ )Zb, <br /> '7p AREA QUAD /t/E * <br /> , ye TYPE <br /> (Mailing Address) FORMS r5� # &u- 146LEs <br /> NOTE <br /> (City, State, Zip Code) <br /> (Are Ca ode - T phone pur=er) <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 /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on-the S _ sideof <br /> box- ".gid_T% approximately 30_UO fee /mile K6.ti \.. <br /> of by -performing the <br /> fo/Kllowin work (description of work) : Bore 0-0 �y'�'•�oS [tla/`.l,� <br /> y gfe Vim' u J <br /> Work will commence on or about (l dill. 1 , Z-oc>- for approximately <br /> �O 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 /> pp <br /> Signature of Applicant - TitleL :6 �� Date <br /> 9 0 ' loo, <br /> MAST&R.PS\FSBS®L (6/00) <br />