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APPLICATION FOR ENCROAC11MENT PERMIT <br /> PLEASE PRINT <br /> Date U�L) n� OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 73652-ro' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE ,�J/ZtiDg <br /> ti VALID. TO 7 0 DRIVEWAYS <br /> (Applicant Name) STREET N Aae. <br /> AREA QUAD 1U$ - <br /> CJ � 1�.0� TYPE <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 /> D <br /> The undersigned hereby applies for permission to.excavate co truct and/or <br /> oth wise encroach on County Highway Right-of-Wa: nn-the G - .'_. side.:of <br /> approximate � <br /> feet/n� <br /> of 0 rw. formi the <br /> followi o k (description o :work) : hot <br /> Work will commence on or about for approximately <br /> D <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 /> =FMSCEML <br /> tire of Applicant - Title � t I• (u`7, Date. <br /> . (6/00) `i <br />