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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 71:;75-2-6 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID y-/off-06 TO 3-//-07 DRIVEWAYS: <br /> (Applicant Name) STREET A441. * <br /> Zt/6S AREA 5'TiC/�/ QUAD W5 <br /> TYPE —S6w HoL6 Bo�E <br /> i (Mailing Address) FORMS 5351i <br /> G4 <br /> vn . 9�� t _ NOTE <br /> (City, State, Zip Code) <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. m <br /> CALIFORNIA 5UPPLEMERMT Q <br /> 0 C �� <br /> 0 rpt <br /> 1 to <br /> 10 7 <br /> CA X <br /> The undersigned hereby applies for permission to excavate, cons uct akd/or '{ <br /> othe w' se encro ch on County Highway Right-of-Way on the sideo <br /> Wipe - approximate feet/ G <br /> of by performing the <br /> fol owing wo _ (description f work) : <br /> 09 <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 /> inspection and approval. <br /> —�V) Aj�&v -&,t T (,�u�, .��tm r <br /> Si ature of Applicant - Title Date <br /> TURN <br /> MAST \FEZSC:tiPL .e/GO) PERMITS TCS: <br /> PGM <br /> BIW r ROMS,3M DESK BW <br /> 4W WON Low <br /> 870M' , CA <br />