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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date U✓ OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7So.57, REF # <br /> Department of Public Works APN CR # <br /> y, <br /> EXP. DATE <br /> �i VALID 6-42-0,7', TO /-I-qg DRIVEWAYS <br /> (Applicant Name) STREET 1A AREA JB�G�►w QUAD <br /> TYPE LL )4611-- <br /> (Mailing <br /> O(Mailing Address) FORMS. <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telepho a 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 /> The undersigned hereby applies for permission to.excavate, c�jn_s•truct and./or <br /> otherwie encroach on 'county-Highway Right-of-Way-on-the -��-., side:of <br /> G-' approximately feet/mij'e Ki/ <br /> of by "performing the <br /> following work (desc iption of work) :a <br /> Work will commence on or about vpl ItEis for approximately <br /> - <br /> days. <br /> I, the undersigned certify that I am the owner of. the re spective, 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 /> 7 <br /> Sioz =a� �n L-ature of Applicant Title Date <br /> . ����r LO-07 - <br /> I+Q1StPS\F=SCEML (6/00) \'\ <br />