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APPLICATION FOR ENCROACHMENT PERMIT <br /> PL33AS PPRINT <br /> Date C OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID QZ??-DS- TO DRIVEWAYS: <br /> (Applicant Name) STREET /1A' 00<.*Y 4) , AD. <br /> tltl AREA QUAD X114," <br /> 1 � � l.► o TYPE L.C., �t <br /> (Mailing Address) FORMS 954vW 2-6 <br /> NOTE <br /> City, State, Zip Code) <br /> I ZI <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 /> `72 <br /> The undersigned hereby applies for permission to .excavate, �n,s:t�r;.u;ct and/or <br /> o herwise-encroach o ounty Highway Right-of-Way o the side <br /> of ;3 <br /> approximately _` feet*10"_ <br /> Of CSD1 by performing the <br /> fowingrk escr tiw k)y p <br /> D C - <br /> Work 3,'ll commence on or about C.L- , 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 /> ins a ion and approval. <br /> A 645D�� <br /> Signature of Applicant - Title Date <br /> MASTER.PS%FRBS®L (6/00) <br />