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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To' San Joaquin County JOB # 73v5Z -'(a REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE��J o.T —08 <br /> VALID T� TO 107/0_8_ DRIVEWAYS: <br /> (Applicant Name) STREET '4o h pe �7/� <br /> ` , p i /;�� AREA s // QUAD �S <br /> A � 1/`�1� L�.�1 TYPE A4 Ale <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 /> �i rr CURRENT M.U.T.C.b. <br /> GL! CALIFORNIA SUPPLEMENT <br /> fI : 4)`73 e5oe,5 <br /> 104eY 1 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach ofz County- Highway Right-of-WaV-oa-the -F, nide..of <br /> approximately —"-' feet/mile , �.�/b <br /> of _ tpfZ►.1F.]'L dVG= , by "performing the <br /> following work (description of work) : to-e F:p1_..be' --` ^f<,A`S <br /> t>5Z,Vi CAnE .1`x.4 ` 4e// %%/t <br /> Work will commence on or about for approximately <br /> Vv�tl 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 /> Sin3PS\FMSC9DL <br /> attire of Applicant - Title � � l+ lG Date <br /> MAS (6/00) <br /> i <br />