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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �C,6�p OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CRI # <br /> EXP. DATE <br /> VALID +12-04 TO 3"J� �I DRIVEWAYS <br /> (Applicant Name) STPft0t 4V. <br /> a)!5,1 . , AREA air QUAD <br /> /LN TYPE D .1-4 <br /> (Mailing Address) O� FORMS SS -Z17 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> S-ket (M ailed plans may be submitted) <br /> 3 TRAFFIC CONTROL PLAN <br /> CO <br /> no _ � SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> U,J 3 CALIFORNIA SUPPLEMENT <br /> -: W0 <br /> C= C <br /> 0 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the 1- 1 si e of <br /> approximately feet/ <br /> of 0F'qp� _ by performing the <br /> fo lowing wor _ (description of work) : <br /> Work wall 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 /> inspection and approval. <br /> Siature of Applicant: - Title �� Date <br /> RAST .E FEESCHDL 1of GG) RETURN PE LWS C TO: <br /> e • "E <br /> JOB PROCESSM DESK- BLD 1 <br /> `040 Wed Lww <br /> �C`.ON, CA 95204 <br />