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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date �lot> OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 7330- ,- REF # <br /> Department of Public Works APN CR # <br /> 1 <br /> EXP. DATE a <br /> VALID TO -f—G DRIVEWAYS: <br /> (Applicant. Name) STREET <br /> AREA 1 J r' r ' QUAD <br /> Lht ► TYPE 2k <br /> (Mailing ddress) FORMS 2TS A <br /> NOTE <br /> a a Zoe <br /> City, State, I Zip Code) - - <br /> Czo!� ��-Z <br /> _._ (.Area._noda.__-_Telephone_Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> 140T Lc>2-1 1700 t) <br /> (�'► .5C)(-Z.`7cf)- 1 <br /> The undersigned hereby applies for permission to .excavate, ,construct and/or <br /> of erwiae-encroach Coursty Highway Right-of-Way-oa �th+e si of - <br /> approximately Qb f-- feet/jc=' <br /> of by "Pe-rfo ing the <br /> fallowing work (descri tion of work) : <br /> An <br /> E� <br /> Work will commence on or about for approximately <br /> !r,> 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 rules6 , regulations of, San Joaquin County and subject to <br /> i c on and approval. <br /> at <br /> Signature of Applicant Title Date <br /> P9LS=.PS\PB9S®L (6/00) - -` <br />