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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:/ <br /> Date �O! I�C.O OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE0(0 <br /> VALID d 7,? 0 O DRIVEWAYS: <br /> (Applicant Name) STREET4?� <br /> STi '7 <br /> AREA QUAD <br /> .�L _ <br /> TYPE <br /> (Mailing Address) FORMS �3 J�•29 <br /> NOTE <br /> (City, State, Zip Code) <br /> 2-- (Meac;Code - Telephone Number) <br /> bW <br /> 3 <br /> tclf=(Dei�ailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 0 C' — aa- SHALL BE AS PER <br /> w�r <br /> ars.; CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> Vv CV W <br /> 1 10 � ►c2.0�5 <br /> The undersigned hereby applies for permission to excavate, gonstruct and/or <br /> otherwise ncroach on County Highway Right-of-Way on the ide of <br /> approximately feet/ D <br /> of by performi.ng the <br /> following work (description of work) : -'+ <br /> Work will commence on or about for approximately <br /> &L? 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 /> Si ature of Applicant - Title Da e <br /> _ - --RET1JFiN PERMRS TO: <br /> NWST .F \,FEESCHDL (G/GO) y� p���c��++ IW <br /> p� <br /> YW r��./M VGSK- SW 1 <br /> W <br /> Q� �^�- <br />