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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date (/ OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE T-/-0-7 <br /> / / r VALID TO f-/-0-7 DRIVEWAYS: <br /> (Applicant Name) STREET 72AAeA <br /> } /' / f AREA s'TdCk7V0 QUAD <br /> i _ <br /> y ( e,5 Z,4 TYPE GC .� /lE <br /> (Mailing Address) <br /> JJ FORMS �!SWN, 2- <br /> S 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 /> RETLM PERMITS TO: <br /> PGM <br /> alOB PROCESSING DESK- SLD I <br /> s <br /> 40401Msst LW* — <br /> a I OC TON. GA 96204 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-ori-the � cJI/ �{ side.of <br /> ZA4. A?�� approximately I ee e % l <br /> of 6t/4 m/ by performing the <br /> following work (description of, work) : r,.x 1 <br /> i4 vim'i'7 ;'v-X <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 /> inspection and approval. <br /> / <br /> Signature of Applicant - Title <br /> . 10 :014 GZ �� l(lOZ Data <br /> MOISTER.PS\FUS®L (6/00) - <br />