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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF <br /> Department of Public Works APN --------�r CR # <br /> f w ✓ <br /> EXP. DATE <br /> VALID 5:/ TO I-/S`� DRIVEWAYS: <br /> (Applicant. Name) STREET 16� <br /> AREAQUAD /fly <br /> TYPE 2� <br /> — (Mailing Address) FORMS -1-5^AU�, <br /> - i NOTE <br /> (City, )State, Zip Code) <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plan: may be submitted) <br /> N„ TRAFFIC CONTROL PLAN <br /> SHALL BE AS PEP <br /> CURRENT M U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> o herwise encroach C ownty ah av Ri ht-of-Tntay o theL�t,1i�t side of - <br /> feet/ E—:8JT_ <br /> TSD � .,-, C�17`i by=performing the <br /> fq-lowing work ( es riptio(n of work) <br /> or- i` <br /> ? 70 <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 /> inspecyti7on and approval. <br /> Signature of Applicant - Title Date' <br /> MAS=-PS\FSBS®L (6/00) <br />