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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date d� OFFICE USE OMY <br /> To: San Joaquin County JOS # 2k-f?•-(O - REF # <br /> Department of Public Works APN CR # <br /> + � <br /> EXP. DATE I t» t_'0-1 <br /> VALID 7 Z3 of TO i-I��� DRIVEWAYS <br /> (Applicant Name) STREET <br /> -� tt AREA MAO QUAD A <br /> 1 + TYPE <br /> (Mailing Address) FORMS 'Z <br /> AL.� ,A NOTE <br /> (city, ate, Zip Cade) <br /> oe <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS <br /> CURRENT M J 7C.o . <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> o herwise encroach on County.Highway Right-of-Way-on-the Svc-rrt-t side o <br /> I approximat l _ feet/mile <br /> of 0 by -performing the <br /> following work scription work) : <br /> Work will commence on or aboutzoo-/ for approximately <br /> �Ddays. <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 descrbed above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspe on and approval. <br /> Signature of Applicant - Title �� Daae <br /> 1 Z •01 WN 9 1 �I��i <br /> MASTER.PS\MMSCXDL (6/00) <br />