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APPLICATION FOR ENCROIONT P£RMIT <br /> pLEASB PRINT: <br /> O'ggICS lass ONLY <br /> 1 <br /> Date — t -7 REF # <br /> JOB # / d S Z CR # <br /> To. San Joaquin County APN <br /> (.t� 7 <br /> Department of Public Works EX-p. DATE r -07 DRIVnAYS: <br /> VALID. TO * �_ <br /> (Applicant Name) <br /> STREETG. ws—rJ QUAD --- * ----- <br /> AREA �.�-_ � <br /> TYPE JjyrtR Z7 — <br /> Aro FORMS <br /> (Mailing Address) NOTE <br /> (City. <br /> State, Zip Code) <br /> (Ares Code - Telephone Number) <br /> Plan may be submitted) TRAFFIC CONTROL PLAN <br /> Sketch (Detailed p SHALL BE AS PEP <br /> RETLMN AERN MS TO: CURRENT M.U.T.C.D. <br /> PeE CALIFOPNIA SUPPLEMENT <br /> jOB pp =SSM DESK BLD <br /> 41040 What L&W <br /> grpCKTON, CA 96204 <br /> onstruct and/or <br /> lies for permission to -excavate, c <br /> side.of <br /> The undersigned hereby app Highway Rigoun <br /> otherwise-encroach <br /> _. ..� <br /> Hig ee mile <br /> otherwise-encroach on C ty. approximately b =.performing the <br /> of <br /> following <br /> work (description of work) 7r Z <br /> S <br /> 69 <br /> for approximately <br /> t.. <br /> Work will commences 0 or about <br /> or am <br /> ed certify that I am the owner of the respective property, <br /> I, the undersign agree to do the work described abovein . <br /> resent the owner and in County and subject <br /> qualified to rep ' regulations of San Joaquin <br /> accordance with the rules, <br /> inspection and approval. <br /> Date <br /> i ature of Applicant - Title <br /> MASTBR.PS\"BSCML <br />