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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 11 ' i rO` : OFFICE USE ONLY <br /> To: San Joaquin County JOB - REF # <br /> Department of Public Works APN CR" # <br /> ATE 5 O <br /> VALID <br /> VALID ? 31 vCo T S Dlp DRIVEWAYS: , <br /> (Applicant Name) STREET I% . <br /> AREA QUAD 25� <br /> Gl9/ TYPE 6Fz1_ 60ya <br /> (Mailing Address) F6p�1�f FORMS '5V <br /> NOTE"' <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAW, rg <br /> SHALL BE AS PER --4 � ' <br /> CURRENT M.U.T.C.D. o <br /> CALIFORNIA SUPPLEMEW <br /> C CA CM <br /> O •� <br /> _0>0510&o © x <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> • approximatelZEM feet/ ,'- EA_[ <br /> of , y performing the <br /> following work (description of work) : Q, <br /> Work wi 1 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 /> 64 C�q 6tmahr <br /> Sit�, <br /> tF�ure of Applicant - Title Date <br /> \FEESCL (6/00) RETUM PERWS TO: <br /> ppry�� `- -- <br /> •bB <br /> PROMSPam <br /> DESK-BLD 1 <br /> � <br /> ��Lam <br /> r T VCKTOKA <br />