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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date A-Y- Z1 LJ OFFICE USE ONLY <br /> TO: San Joaquin Country JOB # 7,K')oS --G REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE /a-'l"e2ig <br /> VALID -0120 TO id /-08 DRIVEWAYS: ..� <br /> (Applicant: Name) STREET 4GiCkeG AW. <br /> AREA rM c-11441 - UAD <br /> ff�LE <br /> W� <br /> TYPE !l- <br /> (Mailing Address) FORMS -'"29 <br /> NOTE <br /> (City, Sta e, Zip Code) <br /> czc�� fAZ- 62 21 <br /> (Area Code - 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 /> The undersigned hereby applies for permission to.excavate, .c struct and/or <br /> otherwise- encroach County Highway Right-of-Way-on-the a'de.of <br /> 4DQ9L-Lapproximately _ feet/ C.�` <br /> of by -performing the <br /> foll ing wo k (description of work) : <br /> �f D <br /> Work1 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 /> inspe n and approval. <br /> -i <br /> Q <br /> Signature of Appl cant - Title <br /> E <br /> MASTSR.PS\FRES®L (6/00) <br /> it <br />