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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ���. OFFICE USE ONLY <br /> TO: San Joaquin County JOB # �3015 REF # <br /> Depart <br /> en of Public works APN CR # <br /> EXP. DATE <br /> . 4 E 0 .( <br /> VALID. � d.C�TO 1 oG . DRIVEWAYS <br /> (Applicant Name) STREET /V/3n r-TA <br /> a,E yF,. <br /> AREA STGLs[Yedlrl QUAD A5 <br /> L,f-/� A TYPE <br /> (Mailing Address) FORMS �WOJ — <br /> � NOTE <br /> (City, State, Zip Code) <br /> (Area Code - "Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> Z, o � SHALL BE AS PER <br /> � .. O <br /> CURRENT M.U.T.C.D. <br /> 5• •ac CALIFORNIA SUPPLEMENT <br /> CIV <br /> C <br /> The undersigned hereby applies for permission to.excavate, "cons•truct'and/or <br /> oth rwise en ach o C ty�Highway Right-of-wa:y�on-the �.�t.!'�4�' si. of <br /> approximat el feet/*mMw <br /> ofAW , by --per€ormiiig the <br /> following work�(descri do f: w rk) : <br /> '� Sze <br /> E O <br /> Work will 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 /> in tion and approval. <br /> Signature of App icant - Title Data <br /> MASTSR.PS\FUSCBDL (6/00) <br /> i <br />