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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> (.,,� <br /> Date -z) -0 U> OFFICE USE ONLY <br /> To : San Joaquin County JOB # z��a-c® REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) <br /> 1 e��—�.• �+----t— ��� STREET Al <br /> AREA SI QUAD <br /> 5 z/o TYPE <br /> y i5lGeS— <br /> Nv <br /> (Mailing Address) FORMS 5� lv e-0 <br /> 47 <br /> 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. <br /> CALIFORNIA 5UPPLEMET <br /> A. <br /> G G <br /> 00 <br /> c <br /> The undersigned hereby applies for permission to excavate, o str ct ar1 /off z <br /> otherwise encroach on County Highway Right-of-way on the `{ %ide of `- <br /> l� approximately feet/mares- Iy":ffi <br /> of b performing the <br /> following wo k (description of work) : <br /> Work /Iwill commence on or about q A[jam for approximately <br /> l� days. r— <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 /> Si ature of Applicant -- Title Date <br /> RETURN�PE'�RCMITS TO: <br /> MAST FEESCHLIL (6%00) �p • GAE <br /> a�e PRMEa3MK� DESK- BLD 1 <br /> 4040 Went Lang <br /> S,1 , CA 95204 <br />