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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date A--r d OFFICE USE ONLY <br /> To: San Joaquin County JOB # � �� REF # <br /> Department of Public Works APN CR # <br /> EXP. DAT d "' <br /> 1 VALID TO la DRIVEWAYS: <br /> (Applicant Name) STREET _ <br /> AREA QUAD <br /> TYPE <br /> (MailAddress) FORMS <br /> NOTE <br /> aj (City,,{ S�`Telep�hone <br /> ta e, Zip Code) <br /> Area Code Number) <br /> Sketch (Detailed plans may be submitted) <br /> -SEE:—: A�� � �K� TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> ® CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> ►�v`�102� ��� 7� <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherise- encroach on County Highway Right-of-Wa n-thea sido.of <br /> approximately - LAtA EEL T1 <br /> of LAL I_ by':Performing the <br /> f llo ing work (desc 'ption 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 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 /> inspection and approval. <br /> Signature of Applicant Title Daae <br /> MASTER.PSNPUS®L (6/00) <br /> I <br /> i <br />