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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE-PRINT.• <br /> Date ) ONCE IISL ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> r� <br /> EXP. DATE <br /> VALID TO DRIVEWAYS <br /> (Applicant Name) STREET 46 f1 <br /> AREA si i= i i. QUAD L,!5 <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> D <br /> (City, S ate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> ,'-'/ ��"� E( CURRENT M.U.T,C.D.eE <br /> C d CALIFORNIA SUPPLEMENT <br /> �L��� <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County. Highway Right-of Way on e Side of <br /> 1--1►� approximately feet/-mD <br /> of " ti' c, by performing the <br /> VIPfollowing work (description of work) : f <br /> work will commence on or about C!3 for approximately <br /> 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 /> Signature of Applicant Title Da e <br /> MASTER.PS\FESS®L (6/00) L - <br />