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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' QE <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7� L ca REF # <br /> Department of Public Works APN CR # <br /> ( <br /> EXP. DATE ` <br /> TO DRIVEWAYS:. <br /> (Applicant Name) STREET lfl !PONS <br /> y _ AREA `'sTck-;JG7p+J QUAD �� <br /> TYPE '-E'SrLt <br /> (Maidling Address) <br /> FORMS :2;_,T,�.+ a ,- <br /> �.J q U��Ml a �$ �✓L 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 /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> ZDC-)o --- IL <br /> The undersigned hereby applies for permission to .excavate, c nstruct and/or <br /> o <br /> oth r ise-encroach on aunty Highway Right-of-Wa o the side:of <br /> r approximately o�fi feet/.qvi4re- <br /> of ��x �"eti$ by performing the <br /> following work (descri tio�5n of work) : <br /> c�`�i'VA' �c Lmot <br /> Work will commence on or about for approximately <br /> 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 rulers, regulations of San Joaquin County and subject to <br /> insion and approval. <br /> 4 D - M AE . - kc) — <br /> Signature of Applicant - Title �� it J Dat <br /> MASTRR.PS\FEES®L (6/00) <br />