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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 1 � <br /> Date l_ 4, OFFICE USE ONLY <br /> TO: San Joaquin County JOB # � ��`jZ REF # <br /> Department of Public Works APN CR' # <br /> j EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET sfur,'1�!'/e o Az� <br /> u1�-J — AREA QUAD s'VL9J <br /> TYPES <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, itate, Zip Code) <br /> �l ® I�AZ� <br /> Lzc� <br /> _--__---.__ _--(Area-.-Code. - _Telephone...Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC SHALL BE CONTROL L PLAN <br /> S PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> . <br /> The undersigned hereby applies for permission to.excavate, c ns:truct and/or <br /> ther 'ee encroach o County Highway Right-of-Wa ..on• l side of <br /> i� approximately f feet/m#�- .(7_4 <br /> of by pez•formirig the <br /> fol wing work ( escripl�i on of work) : <br /> �� b 2 L <br /> Work will commence on oz- about A=A446fS for approximately <br /> �bdays. <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 /> accord ce with the rules, regulations of San Joaquin County and subject to <br /> I pec on and approval. <br /> 4 c); <br /> Signature of App icant TitleI 1 LL. F l G Date <br /> FASTER.MPRES®L (6/00) - <br />