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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -✓ �9 �-`� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR' # <br /> f� <br /> EXP. DATE C� 7-2-62 <br /> G VALID Zooy7 TO (�,-ZZ�07 DRIVEWAYS:. <br /> (App icant Name) STREET 'VA 4-10US )eZ)V. * <br /> l-�c I� AREA -rTaCICT 1*0 QUAD CG <br /> �'�' <br /> TYPE 1Jrf11 $6LL <br /> (Mailing Address) FORMS 55 G✓+�� ,'-Z4 <br /> os � NOTE <br /> A(City, State, Zip Code) <br /> (Area Code - Telephone Number) ' <br /> Sketch (Detailed plans may be submitted) <br /> _ TRAFFIC CONTROL PLAN <br /> e. <br /> SHALL BE AS PER <br /> CURRENT M.U.T,C.D. <br /> "S fe�' a CALIFORNIA SUPPLEMENT <br /> bj z�� l <br /> o <br /> The undersigned hereby applies for permission to excavate, gonstruct and/or <br /> AA otherwise e croach unt - Highway Right-of-Waw-on-the - side of <br /> o 14ALUJCE Pba7Wa-pproximately _ feet/mile <br /> of d mw4 by -performing the <br /> following work (descript1�1ion f work) : <br /> 5 Cd- <br /> law-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 /> i c on and approval. <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FEESCEDL x6/00) <br />