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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date NAA0IC) Io OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR' # <br /> LEXP. DATE -1'5-f90 <br /> ` t VALID -1-1-d8 TO i-�1'5_Urr,� DRIVEWAYS <br /> (Applicant Name) STREET jkt'F rn('O u.>Al/ <br /> -� AREA !Z CCA QUAD <br /> TYPE <br /> (Mailing A dress} FORMSl�a -�.`; <br /> ' Q / E NOTE <br /> ' J L� (City, tate, Zip Code) <br /> (ZnID .® � <br /> __(Area_ Code_ -_ Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PEP, <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, co struc and/or <br /> othe wise encroachn County Highway Right-of- a t-th.e o _— <br /> _ a roximately 1—P _ feet/ <br /> of ,�(,� by -performing the <br /> fol wing work (descr ption f work) : <br /> _P417Ki DCL- <br /> Work will commence on. or about <br /> days. for approximately <br /> - - �� <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 /> inspe n and approval. <br /> Signature of Applicant: - Titlef ; Date <br /> LZ :01 ,l <br /> MASTER.MPRES®L (6/00) <br />