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c • <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4--yy OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> 7 VALID TO 'N-00 DRIVEWAYS:. <br /> (Applicant Name) STREET Ave. <br /> � �� , AREA `,rm c_ .'t�,t�1 QUAD TYPE "?:,C L HOL6 <br /> (Mailing Address) FORMSr =-zg <br /> NOTE <br /> �( ityv�, ta�te, Zip Code) <br /> ._.(Area_Cade _.__Telephone_.Number), <br /> sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> 14-- 1 22 <br /> The undersigned hereby applies for permission to.excavate, con,struct and/or <br /> oth rwise-encro ch on Count Highwa Right-of - oaf-the <br /> Y Y. g Y� <br /> E approximately — feet <br /> of 4• , by performing the <br /> f:9,11ow,ing work (descrintion of:work) : <br /> ® o 1 <br /> Work will commence on or about 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 rules, regulations of San Joaquin County and subject to <br /> i e ion and approval. <br /> At? - 'L <br /> Signature of App icaat - Title ate <br /> NASTSR.PS\FESS®L (6/00) - i <br />