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APPLICATION FOR ENCROACMCKNT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB ## 'j3c>v SG.-Co REF # <br /> Department of Public Works APN CR # <br /> �- EXP. DATE <br /> a C f L - r t VALID 7-7-z>19 TO to-i5--G DRIVEWAYS: <br /> (Applicant Name) STREET i{L�/ 49 r"2vAt Ra. <br /> _ AREA QUAD `:-!E <br /> r 1Y �9 � t 1 TYPE <br /> C (Mailing Address) FORMSw�� <br /> A R NOTE <br /> (City, State, Zip Code) <br /> f , _.. , .. <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> n _.... k TRAFFIC CONTROL PLAN <br /> � , _ <br /> 'fi SHALL BE AS PER r-- N <br /> CURRENT M.U.T,C.D. - <br /> C= <br /> CALIFORNIA SUPPLE <br /> MEt <br /> The undersigned hereby applies for permission to excavate, cc tru and/or <br /> 2�4e ise enc oath on County Highway Right-of-Way-ori-t)�i,e side of <br /> A approximat -- feet/maw r�Ics . l- <br /> of eI A ` , by "performing the <br /> f owin work (descriptio of workl_: <br /> tom( Z. Q l <br /> Work w' commence on or about L-.-r 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 Date <br /> MASPSR.PS\FBBSCHDL (6/00) <br />