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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> J� <br /> Date OFFICE USE ONLY <br /> • ,--�`� <br /> TO: San Joaquin County JOB REF # <br /> APN CR <br /> Department of Public Works # <br /> P / <br /> EXP. DATE <br /> l-y <br /> �L� , VALID. y TO 7- DRIVEWAYS: <br /> (Applicant Name) STREETL'.�L� <br /> AREA 4_, QUAD — -- <br /> �• L 1 TYPE <br /> (Mailing Address) FORMS <br /> / NOTE <br /> (City, tate, Zip Code) <br /> (Area Code Telephone .Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> 7NIC SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> Pio DZ1552 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroac on County Highway Right-of-Wa -on ate side.of <br /> approximate — feet/ _ <br /> by performing the <br /> of <br /> follow work (description of work) <br /> Work will commence n or about 0 for approximately <br /> a <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 ;, „ Dat <br /> MASTER.PS\FRES®L (6/00) <br />