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APPLICATION FOR ENCROACM49NT PERMIT <br /> PLEASE PRINT• <br /> Date �'c�T t OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7:W52,-6 REF # <br /> Department of Public Works APN CR: # <br /> EXP. DATE �l GAS <br /> VALID ,5"/?'a8. TO '9 1 nJ DRIVXWJLYS: <br /> 06plicant Name) STREET ". * <br /> AREA A,.J QUAD <br /> �7 TYPE fie-f/a <br /> (Mailing A dress) FORMSltilu <br /> NOTE <br /> City, State, -Zip Code) <br /> --.(Area -Code-.----,Telephone_.Number)- <br /> Sketch (Detailed plans may be submitted) <br /> //�� TRAFFIC CONTROL PLAN <br /> t-� T �� SKE�LI�k�� SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> v l0 2 Lo <br /> The undersigned hereby applies for permission to.excavate, c at t and/or <br /> oth rwise-encroa on Count-y-Highway Right-of-Way--o .Vhe side.-of - <br /> approximat ly 2 feete -5�a <br /> of iEAVE _T171C�'C Cj by "performing the <br /> following work (descri tion of work) : <br /> 2 ' o <br /> Work will commence on or about for approximately <br /> q� 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 rules, regulations of San Joaquin County and subject to <br /> i ect on and approval. <br /> Signature of Ap licant Title Da <br /> u, <br /> MUTRR.PS\F=S®L (6/00) - - <br /> i <br />