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' 0/05/2006 14: 21 2094689324 PAGE 01/02 <br /> APPLICATION .FOR ENCROACMMNT PARMIT <br /> PT_EAgg_PR�NT: <br /> Date r�V P�. OFFICE' TUSH ONLY <br /> To: San, 7oagfuin County JOB ¢# //ooS REQ' � <br /> Department/ of pthlgic rWorks ApN CR ## <br /> DATE <br /> D1DATEE <br /> V' 1 <br /> (!),C- . VALID. <br /> �ID T0 AR.r'VF4P.A.YS: <br /> (Applicant Name) STMT M&;,egsal &A& <br /> c AREA Soo ck#wi QUAD fii S� <br /> ,Ll 10 WTXQE bo iinA� r <br /> i <br /> (Mailing Addreae) FORMS. <br /> NOTE <br /> (city, grate, .Zip Code) <br /> a -- <br /> (.Area Code - T61aphozne Vbmnber). <br /> Sketch (Detailed piano may be st bmitted) <br /> The Undersigned hereby applies for, permission to .excavate, construct and/or <br /> otherwise-encroach on., otmnty Highway Right-of.-Way-on-the aids+,•of <br /> e- approxi matelY - C ��° e© ile e <br /> of by 'pez€ormi.slg the <br /> following work (description of.• work) : ;. <br /> -h%d G Q. <br /> work will commence on or'about O for approximately <br /> 1!. <br /> days. <br /> Z, the under.sIgned certify. that Z am the ,owner of:the respective propexty, or am <br /> qualified to r•epresdut the owner and agree to do .the work descry.)Ded above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Sigx:tature of Apgldlicant Title pate <br /> IMS7Ek,P9\BSRBCI�L (G 00) <br /> 1 <br />