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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> C/ <br /> Date <br /> W OFFICE USE ONLY <br /> To: San Joaquin County JOB # q3 b 5Z- (a REF # <br /> Department of Public Works APN C12 # <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) <br /> STREET EWla1 AVE <br /> AREA QUAD <br /> p� CS <br /> TYPEZ2LIf f�� r DUE <br /> (Mailing Address) FORMS <br /> 7 NOTE <br /> City, State, Zip Code) <br /> Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PERm o <br /> CURRENT M.U.T.C.D <br /> CALIFORNIA SUPPI EMW <br /> jC� <br /> C <br /> o m <br /> 37�,3 0U> F7 <br /> �o <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otkierwise-encroach on County Highway Right-of-Way-on-the �r/��€'T�� SiEl7r side,-of <br /> �rjj;gin,, �d approximately /'¢ ee /aril <br /> of ~�/,QG�'�R �N. _.S""—X�y'V . . , by --pe-rformirig the <br /> following work (description of work) : T1r_CZ� /rte, <br /> Iv✓/�L/C /vr.i / <br /> Work will commence on or about ZZZZ Z C7 for approximately <br /> 19a _ 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 /> J ignature of Applicant - -Title Date <br /> MASTER.PS\PSBS®L (6/00) + <br /> /�'.Qs 7L <br />