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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date _, y� OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> /� ,✓ <br /> EXP. DATE 2•)S1 S <br /> • '--` VALID JL1.1-'4-9- TO 2• S•D DRIVEWAYS: <br /> (Applicant Name) STREET i0vagrAW. <br /> AREA QUAD <br /> (Mailing Address) FORMS Z <br /> NOTE <br /> (City, tate, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 4� <br /> SHALL BE AS PER <br /> CURRENT M.U.TC.D. <br /> CALIFORNIA SUPPLEMENT <br /> C_, <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County Highway Right-of-Way on-thy ' ' side -of ) <br /> approximately2 ee / SItyT�/ <br /> of aV,�/ fsi✓ r✓. by "per€ormi�q the <br /> following work description of work) ar✓G zwdha C. x <br /> t/C. V 3110 �- y� „ <br /> ♦ se / rt.Ep �!Q6X "X4" 42, 6.0, Rj✓ d.�+l J e- <br /> /' / /' <br /> ' <br /> Work wili commence'An or about Q for approximately <br /> f Z® 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 /> WXTSR.PS\FERS®L (6/00) <br />