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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date - OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 7. 5 _ , REF # <br /> Department of Public Works , APN CR # <br /> EXP. DATE 4 <br /> VALID 7 D L ?. TO DRIVEWAYS: <br /> (Applicant Name) STREET vJoc '3rDC Fes. <br /> AREA A A M Pct OUAD <br /> SCD 1/�1��0 f <br /> LW <br /> � TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, .Zip Code) <br /> (Area Code - Telepho a Number) <br /> Sketch (Detailed plans may be submitted) <br /> T <br /> RA' <br /> FFIC CONTROL'PLAN, <br /> ' <br /> 5HA4L•E, AS PER.; <br /> r CURRENT M U.T C©. <br /> L! CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, .construct and./or <br /> otherwise-encroach—oii'Count Hi hwa Right-of-W& ox-the side__of <br /> �. y�coAlori&lP_ 64 approximate) 0 feet/m:*e Eaf2k <br /> of ti�P1 y erformirig the <br /> fol) wi g work (des p 'on of: work) : 14, Ono <br /> Work will commence on or about 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 /> inspection and approval. <br /> ridA1110 I <br /> Siature of Applicant Title Date <br /> MAS .PS\F=GCE1DL (6/00) - <br />