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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date <br /> (o _'Z S CR-7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # �S Z REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID g'l'D7 TO '/-07 DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREA STOG,E�6�✓QUAD <br /> 404ro W6fZ (—W4 C TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> _�To cwt-rra►J cam. �l <br /> (city, /State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> �M 3o�14s5� <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on-the Sou—rlA side of <br /> yn '`j"�' approximately i•4r5' ee /mile W*.ST <br /> of YSJ \2.20¢- AIG by "per€ormirig the <br /> following work (description of work) : -��`-r1�1�1.1-iw�P <br /> Work will commence on or about for approximately <br /> Z 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 :rulers, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> I0 AT _ZQ <br /> Si ature of Applicant - Title S� ;�I �� (' �[ I, Date <br /> MASTER.PS\FEES®L (6/00) <br />