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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (� Z� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID /0-99-o7. TO a?-/- DRIVEWAYS <br /> (Applicant Name) STREET i9BL�iY <br /> i, AREA �/�/l�f UAD <br /> A� 1 [ A Z TYPEAa <br /> (Mailing Address) FORMS Gfllf> 29 <br /> NOTE <br /> (City, State, Zip Code) _- <br /> (Area Code - Telepho Number) . <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PEP, <br /> L CURRENT M.U.T.C.D. <br /> J 1� CALIFORNIA SUPPLEMENT <br /> 3as � ZSL1 <br /> Y <br /> The undersigned hereby applies for permission to .excavate, .construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on-the side -of <br /> 9,4W11,P^ flo/ approximately — feet/mile It <br /> of - - fbP by 'performinnq the <br /> follow g work (descript:ion of: work) ell — )Aa 4- 13a+-,0 /k <br /> A) -9 6745 sve- <br /> Work will commence on or about — !0- 29-Ot for approximately <br /> g C7 <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 /> Siature of App cant - lriL­ Date <br /> MAS .PS\nMSCE1DL (6100) \ . <br /> i <br /> i <br />