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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:. <br /> Date U OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE Z-lS-vB <br /> ti- VALID. TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA -5r1,CA1 QUAD <br /> TYPE <br /> (Mailing Address) FORMS "z9 <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 /> L' CURRENT M.U.T.C.D. <br /> L CALIFORNIA SUPPLEMENT <br /> --)oC_)o06-ice <br /> . t L <br /> The undersigned hereby applies for permission to-excavate, construct and/or <br /> oth rw'se a croach on County Highway Right-of-Wa:y-os.-the -...side. -of <br /> approximate feet/fit ' <br /> of ? A by "performing the <br /> following work (description of: work) : ' <br /> C <br /> Work will commence on or about ` `07 for approximately <br /> Lf�C1 <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 /> Siature of Applicant Title �O :�� 1� ��°; ;ik �1JU� Dat <br /> 14: .PS\FESS®L (6/00) <br />