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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date —V-3 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7305Z-(,, REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE -7.1 T-()'? <br /> CLQ VALID -?-/-0'7 TO 7. ),5_-eJ7 DRIVEWAYS: <br /> (Applicant Name) STREET H?661 VS AVE_ <br /> AREA ;�?� � S2UAD <br /> Z <br /> tv TYPE ([ f01E <br /> (Mailing Address) FORMS <br /> e <br /> 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 /> To CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> a c� <br /> _ - trJ <br /> . 3 3� <br /> Thi unde3wigi�jed hereby applies for permission to .excavate, construct and/or <br /> otAefwise encroach on. County Highway Right-of-Way ora-the N�V=(U side-of <br /> t5_ 4Eapproximately fee /mile <br /> of. by "performing the <br /> followin-work (description of work) : 2-" <br /> Work will commence on or about -7— t �' (� 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 /> C)7 <br /> i.gnature of Applicant - Title Date <br /> MASTSR.PS\FESS®L (6/00) <br />