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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � / OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> ` EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> Al, AREA QUAD <br /> Al <br /> TYPE <br /> (Mailing Address) FORMS <br /> NOTE <br /> 0-�-�--I)A qS 04- <br /> (City, Aotate, Zip Code) <br /> L'4�v-q I) ?wZ-- /s!& <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) 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, constru t and/or <br /> otherwise encroach_Qn -County Highway Right-of-Way-on-the side of <br /> approximate1 fe /mime ales7.. <br /> Of 4�y;ay R9. G by performing the <br /> following work, (description of, work) : <br /> a .V Ser v RC2 a�" �9l0/ �,t,lct�,Dry vc. v , ;moo ;, `vi✓ <br /> .� <br /> Work will commence on or about for approximately <br /> 9� 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 /> MASTER.PS\nHSCHDL (6/00) <br /> i <br />