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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date '�� OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73d5Z REF # <br /> Department of Public' Works APN CR # <br /> Exp. DAT , 3'1- o - <br /> VALID. <br /> ALID Zo 07 '. TO 3-1-o* DRIVEWAYS: <br /> (A`p'p�licant Name) STREET A 5- <br /> �AO V�l� P.REAAvi <br /> STi+� QUAD <br /> TYPE _LC-L4-t-10-E <br /> (Mailing Address) FORMS. �S ltJty, J1Zy <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 A5 PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA 5UPPLEMENT <br /> � � <br /> The undersigned hereby applies for permission to.excavate, .cons•truct and/or <br /> of erwis -encro---h on County Highway Right-of-Way -the s.'de::of <br /> � approximately feet/tom _ <br /> Of by 'p rforming the <br /> f llowing work (description of: work) <br /> oar VhWJLd, ai 122M 9- .1 <br /> Work will commence on or about 5110'1 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. y <br /> tSiatLuiar,eof Applicant - Title �+ :01 P. L i : k ° [I�JL Date <br /> F= ®L (6/00) <br /> i <br /> ' I <br />