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a <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> OFFICE USE ONLY. <br /> Date <br /> JOB # 7305 Z- REF # <br /> TO: San 7oaquin' County APN CR # <br /> Department of Public Works , <br /> EXP. DATE 3-.(-d8 <br /> C� <br /> VALID. /d-z2-off. TO -!'a� DRIVSWAY3: <br /> � <br /> (Applicant Name) STREET <br /> AREA: 1rIL _ QIIADS <br /> TYPE <br /> (Mailing Address) FORMS $51.n1y <br /> NOTE <br /> (City, State, .lrip Code) <br /> (Area Code - Telephone Number).. <br /> Sketch (Detailed plans may be submitted) TRAFFICCONTROL PLAN <br /> SHALL BE AS PER <br /> G CURRENT M.U.T.C.D. <br /> 1: CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, .construct and../or } <br /> otherwise-encroath-on County--Eiighway Right=of-.Way•oa.•the �s��`y► gide::of :- :: <br /> approximately 4'ZS' feet/=*i;* <br /> of �a� ami .,. by per€orming the <br /> following work (description of: work) : t4 T-1e -�N ��� I��?41►�'�T <br /> work will commence on or about 1U - ZZ-C!i for approximately <br /> 1-E�o days. <br /> I, 1.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 rule s,, regulations 'of San Joaquin County and subject to <br /> inspection and approval. <br /> Oz-o-1 <br /> Si ature of Applicant Title '01 We Date <br /> C z0qZ�4 <br /> MASTSY.PS\P=S®L (6/00) - - <br />