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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ]0:7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 3dS Z-Cir REE # <br /> Department of Public Works APN CR' " # <br /> j <br /> EXP. DATE <br /> VALID �I-/D-07. TQ DRIVEWAYS: <br /> (Applicant Name) STREET WASN1�To)J <br /> l�D 1/��� � AREA 3Tk�1 QUAD E-5 � <br /> TYPE GL O &R6 <br /> (Mailing Address) FORMS <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 AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> 01 <br /> a M- <br /> The undersigned hereby, applies for permission .to.excavate, construct and/or <br /> o - erw'se encroach on County Highway Right-of-way-on-the l '1 side of <br /> approximately © _ feet/mi&e <br /> of y y y 'per ormi g the <br /> following work (descript:ion of work) ' <br /> 11Q <br /> Work pwill commence orl or about O 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 /> Si at-are of Applicant Title � ` �t ✓ ` <br /> l J D to <br /> MAS .PZ7 S\MSCBAL (6/001 - ,, -y'�{ G1S l a•'��'i .- <br /> C�V ,1 <br />