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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date ZI �D OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 10--/-e8 <br /> C� , [ �7 • VALID IP-13-49 TO /O-•%o8 DRIVEWAYS: <br /> . (Applicant Name) STREET f�/� 5�7- * <br /> . AREA �dc-r�`J�3,✓QUAD �S/•S <br /> 1 TYPE 4LE= <br /> (Mailing Address) FORMS(fA 76Z-.64- Gy6� <br /> NOTE <br /> (Ci y, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitty,e�,d)) TRAFFIC CONTROL PLAN <br /> �9 SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> ( �ZD <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> of ise- e croach n Count-y Highway Right-of-W .on-Of! �-/� sid _of <br /> approximate) feet/• C.5 <br /> of by "per€orming the <br /> f lowing work (descripti n of workh: <br /> C <br /> !� , <br /> Work will commence on or about for approximately <br /> �Ddays. <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 /> ins on and approval. <br /> Signature of Appli ant - Title i ;�� Date <br /> l4lSTER.PS MS®L (6/00) <br /> I <br />