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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date v� OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7SZ'ro REF # <br /> Department of Public Works APN 7 CR # <br /> EXP. DATE � • <br /> VALID. <br /> 1TO - r DRIVEWAYS <br /> (Applicant Name) STREET QIA Si• <br /> AREA ck.•ft QIIAD L-s <br /> � y �to— �N TYPE <br /> (mailing <br /> Address) FORMS <br /> (j/✓� C.,�!• ����"7' NOTE <br /> (City-, State, Zip Code)- <br /> � f) f,�- z -/.!r64- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> ---}.� TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> ------ - - — �- CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> P?Z1.393 71 <br /> The undersigned hereby applies for permission to excavate, con .tr t and/or <br /> otherwise- croach n County Highway Right-of-Wa os thfe side of <br /> , �.�� . approximately a /mile /.(leffT, <br /> of by performing the <br /> following work (dpscription of work : 6 der' 4s <br /> Work wi 1 commence on or about Z 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 /> a.gnature of Applicant - Title Date <br /> MASTER.PS\BEES®L (6/00) <br /> I <br />