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�-�3654 <br /> APPLICATION FOR ENCROACMUENT PERMIT <br /> PLEASE PRINT- <br /> Date s OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 15 D <br /> VALID j z.15•aB TO 15-/D�; DRIVEWAYS: <br /> (Applicant Name) STREET1��'y1D�t7j ✓E <br /> AREA QUAD <br /> TYPE L <br /> (Mailing Address) FORMS 5� 1✓/ z� <br /> CAsz6kNOTE <br /> (Cit'j, State, Zip Code) <br /> ell <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 /> The undersigned hereby applies for permission to .excavate, tract and/or <br /> o �erwise-encroach n ty Highway Right-of-Wa oae nide.of - <br /> approximat 1 feet/�e3ie- ��ZT <br /> of .- VIE by --performing the <br /> following work (descript'on of work) : <br /> a <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 /> in n and approval. <br /> Signature of Ap lioant - Tit a Da e <br /> HHSTER.PS\FEES®L (6/00) <br />