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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date ` OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 36 SZ- REF # <br /> Department of Public Works APN CR # <br /> �- EXP. DATE `t O <br /> (� 1 _ VALID• IA4 TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA STUC- M2p QUAD S S <br /> TtJ C� I �IV TYPE <br /> 1 <br /> (Mailing Address) FORMS 5 5 � <br /> NOTE <br /> ;fi� <br /> / q (City, Sta �eZi�pCo��e) �� <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> 5HALL BE A5 PER <br /> CURRENT M.U.T.C.D- <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otlae ige r ac-h on County Highway Right-of-Way oa-the ER f side.:of <br /> 2. approximateI feet <br /> of by performing the <br /> foLlowing work (de ription work <br /> )J:5 <br /> Work w'llcommence on or about D for approximately <br /> d 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 /> Signature of Applicant Title !J 9S :01 WV <br /> 0 330 901 ate <br /> MTrRR.PS\FRHSCHDL (6/00) i•J E /ryy •y yy �pp <br /> icif <br /> i <br />