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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:' <br /> Date I Jo'7 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID. 8-26-6 . TO 9-/-06 DRIVEWAYS: <br /> (Applicant Name) STREET /2 97 <br /> AREA QUAD <br /> /-tfJ�� V�l: ►hU rCs TYPE AAE <br /> (Mailing Address) FORMS -5 Mu w, 2-7- <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telepho a Number) . <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> ✓ ��' CALIFORNIA SUPPLEMENT <br /> a <br /> G <br /> The undersigned hereby applies for permission to.excavate, .con -truct and/or <br /> otherwise- ncr -._h on..CountyHighway. Right-of-Wq; -.oaf-the 8'de.: f.: <br /> approximate y feet/mom <br /> of �� " by 'p r the <br /> following wo k (descriptio of: work) : ormirig l <br /> !2 17b- <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 /> Sinature of AppL � <br /> licant - Title "' .a '"( _. Delta <br /> h �Q1 L I J(iN � � <br /> MAS .PS\MSCaDL (6/00) <br /> 1 <br /> i <br />