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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z. OFFICE USE ONLY <br /> To: San Joaquin County JOB # /3osz' REF # <br /> Department of Public Works APN CR # <br /> EXP. DA E <br /> q� 4 VALID 4 6 TO Z?-- DRIVEWAYS:. <br /> DRIVEWAYS <br /> (Applicant Name) STREET D� <br /> AREA 516c, O QUAD _ �s <br /> TYPE &>_AW^ <br /> (Mailing Address) FORMS <br /> L� NOTE <br /> L� Q ✓ GOUrI'TFY �J20�E,G'� <br /> (City, StAte, Zip Code) <br /> CZ0 ID–f+z <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ,� TRAFFIC CONTROL PLAN <br /> )EE _� SHALL BE AS PER <br /> —` �– CURRENT M.U.T.C.D. <br /> FORN UPPL€M€, T <br /> - ---- <br /> The undersigned hereby applies for permission to excavate, onstruct and/or <br /> otherwise a croacYiton County Highway Right-of-W y on the side of <br /> t. .1 approximately 4e14 feet/mile <br /> of by "performing the <br /> fol owing work (description of <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 /> in on and approval. <br /> Signature of Appli ant - Title Date <br /> MASTER.PS\FnSCEDL (6/00) - <br />