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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> OFFICE USE ONLY <br /> Date ' —�-- <br /> JOB # �`y2�, c - REF # <br /> To: San Joaquin County CR # <br /> DepDepartmentApN <br /> of Public Works .PNEXP. DATE <br /> VALID i -C�` TO DRIVEWAYS: <br /> (Applicant Name) <br /> STREET ��'� <br /> AREA QUAD /I <br /> 4c& TYPE <br /> (Mailing Address) FORMS. = <br /> NOTE <br /> (city,'? ate, Zip Code) <br /> 4-2 - l <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> Ac G to" � CALIFORNIA SUPPLEMENT <br /> G. <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ,(.[ s ids io <br /> oth ise-encroach on ounty Highway Right-of-W on-the feet/ ��71 <br /> approximately <br /> �Dc , ��—p�" by—Performing the <br /> of <br /> following work (description of work) <br /> for approximately <br /> a. <br /> Work will commence c or about <br /> QO <br /> A - 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 /> in n and approval. <br /> -Cot <br /> Signature of App <br /> lic t - Title Da e <br /> MASTER.PS\FBES®L (6/00) <br /> t <br />