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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 � .� OFFICE USE ONLY <br /> To: San Joaquin County JOB # 3d52--(n REF # <br /> Department of Public Works APN CR " # <br /> f <br /> EXP. DATE Z)S-w) <br /> VALID -7- L-0 7*. TO DRIVBWAYs: <br /> (Applicant Name)j/ STREET <br /> ��CD �1�..0� L�,�l.� � AREA STtsG�`1'Q,17 QUAD �Uc� * . <br /> TYPE 7Z.f�Lc i+,loLE 7 r��Cly <br /> (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 /> ��rr� CURRENT M.U.T.C.D!' <br /> L• CALIFORNIA SUPPL5ME9F <br /> The undersigned he applies for permission to.excavate, .cons.truct and/or <br /> of erwise-encroach orf-County hwa Hi Right-of-Way--on <br /> � g Y. -the � � =: side of -. .-. . . <br /> approximate1 "� ' feet/ate " <br /> of LIF t1le. RE by -Performing the <br /> following work (description of: work) <br /> Work will commence on or about for approximately <br /> If�� <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. y <br /> 6� <br /> -hrnA ,- <br /> Siattire of Applicant Title ate <br /> MASn1VS\F=SCHDL (6/00) <br /> I <br />