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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date fJ OFF'ICE USE ONLY <br /> To: San Joaquin Country JOB # REF # <br /> Department of Public Works APN CR ## <br /> EXP. DATE -/5.- <br /> VALID - _C TO DRIVEWAYS: <br /> (Applicant: Name) STREET �A}Qk_U-y A W, <br /> AREA STuc__i<T6 dJ QUAD <br /> TYPE SEI,(- \-Ao - _ 1?�>e_e- <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> — 61AL, 6 <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE A5 PER <br /> /-� CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> o �5z <br /> The undersigned hereby applies for permission to.excavate, .cons: ruct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on-the side.:of <br /> 1 approximatel feet/fie �(p� 4- <br /> of G by -performirig the <br /> foll w'pg wor (desc:ri tion of: work) : I9 ` ` <br /> -- _ d�(L 1 fit/ <br /> Ea <br /> Work will commence on or, about for approximately <br /> - L' 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 /> Si ature of Applicant - Title °`" - ..ate <br /> - MAS .PS\F885®L (6/00} <br /> i <br /> i <br />