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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �/� / OFFICE USE ONLY <br /> - f <br /> To: San Joaquin County JOB # -73bSZ' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID ""0`7 TO I-!-W DRIVEWAYS <br /> (,App- <br /> licant Name) STREET /E <br /> - <br /> AREA �XllJ�d QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telepho a 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 /> 1DZVMII <br /> The undersigned hereby applies for permission to.excavate, cons: ruct and/or <br /> othe wise-encroach-on County Highway Right-of-W& "0n_--the side:•of <br /> approximate) feet/mietie -1nr _ <br /> of J by -pe forming the <br /> followin work ( escription of.work) : <br /> U�2 OW <br /> Work will commence on or about 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 /> 2 <br /> Jbi <br /> Si ature of Applicant - Title 9Z :�4 � +', Date <br /> MAS .PS\F=SCEML (6/00) <br /> I <br />