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t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # �� %Via`"�� REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE f� eta <br /> VALID 3-17--e9,0, TO DRIVEWAYS:. <br /> (Applicant Name) STREET <br /> AREA d�?�,,,076C,6 QUAD <br /> TYPEG!-f7'G�G <br /> (Mailing Address) FORMS <br /> — NOTE <br /> City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> I�E CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, const uct and/or <br /> oth rwise-encroach on County Highway Right-of-Wa -oi-the side of <br /> approximately i--- feet/mile 5ou'G74- <br /> of , �4 14rby—performing the <br /> following work (desc:ri tion_ of work) : <br /> ® ,6�T�1/�TE S tJ�c f ae D E�lau7i vim{ o t <br /> Work will commence on or about :5/17 /0EE 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 rulers, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Applicant - Title jf; ' Date <br /> MASTER.PS\PEES®L (6/00) <br />