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APPLICATION FOR ENCROACEMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> Date <br /> z JOB # ��5�`� REF # <br /> To: San Joaquin CountT <br /> Department of Public Works APN CR' # <br /> Exp. DATE 12' I'p1 <br /> VALID f11.$-07Td IL- 1-0-7 DRIVEWAYS <br /> (Applicant Name) STREET A1PtGbzr L&ny <br /> AREA dV1,b!J'« QUAD 5G _ <br /> TYPE SLG, �OG6 <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone 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 /> 0 <br /> The undersigned hereby applies for permission to.excavate, cpnstruct and/or <br /> otherwise encroach o County Highway Right-of the side_of -4 <br /> of <br /> 5�1 fi feet/ 's LeL4 <br /> of a`�N/�.ri` rte• by "performing the <br /> f l,Iowing work (description of w k) Q <br /> 411 <br /> t d v <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 /> ins i and approval.. <br /> ALA a ��� 2�0� <br /> Signature of Applic t - Title Date <br /> MASTER.PS%MMSCEDL (6/00) <br /> I <br /> 1\ <br />