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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> � VALID. TO DRIVEWAYS: <br /> ( PPlicant Name) STREET <br /> AREA QUAD /V <br /> r KI a TYPE A/Ot�- <br /> (Mailing A dress) FORMS 4" 09 <br /> NOTE <br /> City, State, Zip Code) <br /> ell <br /> `74Z— 1 A-fz�gl <br /> (Area_ Code-.---_.Telephone_.Number)- <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> DEE AfAL�6GM SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> v , t02 2 w <br /> The undersigned hereby applies for permission to.excavate, c str t and/or <br /> oth rwise-encroa on Count-y-Highway. Right-of-Way--o.1-�he _. side..of <br /> approximately 2 feet/e <br /> of by -'performixig the <br /> following work (descri tion o£:work) : <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 rules, regulations of San Joaquin County and subject to <br /> i ect on and approval. <br /> L) <br /> 47 <br /> Signature of Ap licant Title 90 <br /> iM1 "s u JVU(. <br /> MASTER.MPEES®L (6/00) i <br /> I <br />