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APPLICATION FOR ENCROACMM4T PERMIT <br /> vr.�.AS8 PRINT <br /> Date <br /> �I(1V �()f)F - OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 4.3 SZ. co' REF # <br /> Department of Public Works , <br /> APN CR ' # <br /> / EXP. DATE <br /> 7 . ' • (..rO <br /> VALID- TO DRIVEWAYS: <br /> (Applicant Name) STREET J+A <br /> ' _t { AREA -,ro hmP QUAD -OR <br /> �� W L iV. • TYPE -EEA-A-l4°tF- t. T <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, zip Code) <br /> (Area Code - Telephone Number) . <br /> Sketch .(Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> 4 X4` 8 u- <br /> 1 - 12x42. 'ieW-Odd <br /> The undersigned he applies for permission to.excavate, construct and/or <br /> sid .:of <br /> o herw'se encroach on County Highway Right-of-Way--oa the - <br /> ' approximat'ely feet,/d'3a <br /> 16 <br /> r by per€ormirig the <br /> Of <br /> R.owing work Sdet Qf work; <br /> Work will commence on or about <br /> for approximately <br /> W 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 /> inspe on and approval. <br /> s�42i0M +� �rl no ;d3�' NOV 3 0200 <br /> ignature of Appl cant Title " _ 030 50OZ Date <br /> XkSTSR.PS\F68S®L (6/00) <br /> G3A13:3 <br />