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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / T OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Z I 0 <br /> VALID• d TO / 0$ DRIVEWAYS: <br /> (Applicant Name) STREET �� <br /> L AREA �dt.�eTSnl QUAD <br /> TYPE ACL NoGE T <br /> (Mailing Address) FORMS. ��� <br /> NOTE <br /> (City, State, Zip Code) <br /> } <br /> (Area Code - Telepho a Number) _ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PEP <br /> G CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, -construct and/or <br /> oth rwise- i L, <br /> - encroacYi-on* -Co-Countg ghwa y, Right-of -the <br /> approximately ( feet/mi*e <br /> of y performing the <br /> following work escription of. work) : <br /> LzezWA <br /> Work will commence on or about <br /> 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 /> 4 Si ature of Applicant - TitleI :0I I ' I `�f f Ut�� Da <br /> .PS\F=SC0)L (6/00) <br /> ,i <br />