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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> TO: San Joaquin County JOB REF # <br /> Department of Public Works . APN CR ' # <br /> EXP. DATE (- <br /> VALID•ft <br /> TO 3-I'�� DRIVEWAYS:(Applicant Name) STREETC A61e-ADB sr.^ p AREA S;'7t; QUAD L4)5 <br /> TYPE EGL NotO d T�ENctl <br /> (Mailing Address) FORMS STw� -ZS <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 /> �C CURRENT M.U.T.C.b. <br /> G CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, .cons•truct and/or <br /> othegrwiW <br /> encroa h on Count-y.Highway Right-of-Way-on-the ` side_.of <br /> approximately feet, e-of by --performin-g the <br /> following work (de cription of. wo k) : <br /> h Uz 9 <br /> Work will commence on or about -) for approximately <br /> � Cd <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 /> A <br /> Siature of Applicant Title SZ :01 WN 1 _ 0)51 1017 Date <br /> MASnPS'\MSCEM L (6/00) <br />