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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> rn �s <br /> Date BAR - 9 2006 OFFICE USE ONZYb <br /> To: San Joaquin County JOB 7.3aSZ-�o RE xa <br /> CRS-y»l�rt <br /> Department of Public Works PSN — C <br /> EXP. DATE --` . <br /> "7 <br /> VALIDOU <br /> O <br /> (Applicant Name) STREET <br /> AREATi4pC,�_ <br /> QUAD r-)� <br /> +�f •' TYPE 'BELL - --= <br /> (-M4a-iliY�Gng Address) FORMS 5�� <br /> NOTE <br /> (City, tate, Zip Code) <br /> (Area Code - Telephone Nvmber) - <br /> Sketch (Detailed plans may be submitted) 8371 <br /> tN <br /> 4 <br /> Q g' <br /> -� (1) 4X4 15F_u.-0a.F_ <br /> The undersigned hereby applies for permission to excavate, constructOand/or <br /> otherwise encroach on County Highway Right-of-W on the �e of <br /> — approximate1 2 feetf�3e <br /> Of �Q Q.�uC by performing the <br /> following work (description of work) : <br /> T7FA4a �a�_ FLUE <br /> Work will commence on or about for approximately <br /> 10 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 /> in ion and approval_ <br /> MAR - 92006 <br /> Tit' Data <br /> Signature of App lcaiat - o <br /> MASTER.PS',,FEESOML (6/00) - <br />