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APPLICATION FOR ENCROACMdENT PERMIT <br /> PLEASE PRINT <br /> Date . �J1_a_X <br /> OFFICE USE ONLY <br /> To: San Joaquin county JOB <br /> Department of Public Works # _� REF # <br /> AREA_5 QUAD <br /> TIYPE <br /> J ' v EXN CR` <br /> # <br /> EXP. DATE to ! Q9 <br /> VALID O O <br /> (Applicant Name) STREET ,Q,q DRIVEWAYS: <br /> (Mailing Address) <br /> FORMS �`S/IkLf �9 <br /> 6G � 9�Z� NOTE <br /> (City, State, Zip Code) <br /> Z__ ¢Zr--- <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 /> r <br /> T )141� `d3 7�O Z8 <br /> The undersigned hereby applies for <br /> otherwise-encr ach on County HighwayeRlght-of_y rmission excavate, construct and/or <br /> Right-of- <br /> dr-r- !'✓d &-4 . y on-the —_ JQ�`�. s i- <br /> of G approximately (Fe-0/mile vu f <br /> d!1/ G <br /> following work (descr'ption of work) : Ne" by performing the <br /> moo,, Ok <br /> Gc/ Jam! CTr _ o OG vii <br /> Work will commence on or about <br /> days 7 for approximately <br /> I, the undersigned certify that I am the owner of the respective <br /> property <br /> qualified to represent the owner and agree to do the work described above, <br /> inr am <br /> accordance with the rules, regulation <br /> inspection and approval. s of San Joaquin County and subject to <br /> Signature of Applicant - Title <br /> MASTER.(.PS\FEBS®L (6/00) Date <br /> I <br />