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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> JAN 1 6 2007 OFFICE USE ONLY <br /> L � <br /> To: San Joaquin County JOB # X30�Z -Cc REF o <br /> Department of Public Works APN CR' <br /> EXP. DATE <br /> VALID TO DRIVEWAYS: <br /> CL�(Applicant Name) STREET /��/r(�E AQP *__J <br /> AREA , QUAD AS - * - <br /> ST TYPE ?'aw l.E,Boee; TiQtA.ICH <br /> (Mailing Address) FORMS �f /Z"29 r_ W <br /> NOTE — W Ln <br /> (City, St te, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> 5 Al 9 EC CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> At <br /> o x22236=b <br /> The undersigned hereby applies for permission to .excavate, con .tract and/or <br /> of a ise- encroach on Count Highway, Ri Right-of oa-tlae W C5 side.of <br /> Y g Y.. <br /> L, {�� approximately feet/ ! <br /> of tr <br /> Lp k.� erforming the <br /> following work (descri tion of work) : <br /> Work will commence on or about PlCa . S 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 /> ins n and approval. <br /> 4.®e JAIL 1 6 2007 <br /> Signature of Applic t - e Date <br /> MXTM.PS\PSBS®L (6/00) <br /> II <br />