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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �� l+ 2� � OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73o52-G REF # <br /> Department of: Public Works APN CR # <br /> EXP. DATE <br /> ` ` J VALID 9-/0-07. TO /-0 8 DRIVEWAYS: <br /> (Applicant Name) STREET (1-49240uS AbA05 <br /> 4 4�Gic.�� �I� AREA STdG/CTall) QUAD CS <br /> 1 TYPE 75E1.e Noc.E t TJ�JICH <br /> (Mailing Address) FORMS SsT w <br /> NOTE <br /> (City, S ate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS <br /> "—e f-i� �� ��� CURRENT M.0 T.C.0. <br /> CALIFORNIA SUPPLEMENT <br /> GrE <br /> �o ,�''''"o of--:E� (-A- --7 <br /> The undersigned hereby applies for permission to.excavate,,/construct and/or <br /> othe ise- encroach on County Highway Right-of-Way-on-the Yi &DLA,5 side of <br /> approximatel S feet/mile <br /> of bLt:s p , by .per€ormirig the <br /> following ork (descri do of: work) / D MQrQ �.� <br /> AJDS r 10&5:: Z <br /> f.Q d AJ- <br /> Work will commence on or about 10 for approximately <br /> days. <br /> I, the undersigned certify that I am the owner of. the re spective, 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 e io and approval. <br /> SF's tai. <br /> Signature of Appl can - Title Dat <br /> MASTER.PS\FRES®L (6/00) <br /> i <br />