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APPLICATION FOR ENCROACENINT PERMIT <br /> PLEASE PRINT: <br /> Date NOV 4 2M OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7-"0P REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID v"' TO 1 Z^)15=o4 DRIVEWAYS: <br /> (Apple icant Name) STREET Gr �F�a.�s � <br /> AREA <. UAD it/S <br /> g 1 L_,&M_ TYPE 'tn� 1�b7eL <br /> (Mailing ddress) FORMS - <br /> NOTE <br /> 10 0� LAg 5 <br /> (City, Sta e, .Zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans may be submitted) <br /> _ TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER m <br /> CURRENT M.U.T.C.D.� <br /> CALIFORNIA SUPPL�VIEff <br /> C <br /> 00 <br /> CM <br /> _r 7a• �� <br /> G t'C <br /> The undersigned hereby applies for permission to.excavate, .cons•truct and/or <br /> otherwise-encroac o County Highway Right-of-Way.o�-the aid ,: f <br /> approximately feet,4pd" <br /> of �' j• by " e-r f <br /> 0=incl the <br /> iworkes �ption of LE Wfollow <br /> Work will commence on or about for approximately <br /> days. <br /> I, the undersigned certify that I am the owner of. the re spective, 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 /> 14&e <br /> Si9n ature of APP licant Title I IDate <br /> NLSTBR.PS\nWC8DL (6/00) ` <br /> j <br /> i <br />