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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -Z, L' Q-7 OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN Ca # <br /> EXP. DATE - <br /> �, VALID /f/i=�t"' TO 05 DRIVEWAYS <br /> (Applicant Name) STREET - Jr <br /> / AREA QUAD <br /> / Alf- <br /> VD UJ f� G�cp TYPE " <br /> (Mailing Address) FORMS `�✓� f � "� <br /> NOTE <br /> S oGK�vt C�� 4SZoy <br /> (City, State, Zip Code) <br /> 2DQ- ?`/z_- 1,76 d <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwiseencroachon County Highway Right-of-Way on-the side.of <br /> f5j-&WD7 0 of approximately ASN feet/mile i,✓e.:5' <br /> of r 1e�1 GvC�lorof by "performing the <br /> following work (Ascription of work) : 73 <br /> run A1.6 �!5' ifvtc -e <br /> Work will commence on or, about //-/ D 7 for approximately <br /> q J 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 /> 7-j -7 <br /> Signature of Appl carat - Title �pDate _ <br /> .17 MASTER.PS\FESS®L (6/00) <br /> i <br />