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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> NOV - 4 2006 <br /> Date OFFICE IIS8 ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID1-ftjO-Dlo TO M DRIVEWAYS <br /> (Applicant Name) STREET :50*0 2A <br /> �� W� L�,HINE AREA �. cn� QUAD 166_ <br /> TYPE t: 6&f_4_: <br /> (Mailing Address) FORMS- <br /> NOTE <br /> D <br /> (City? <br /> State, .Zip Code) <br /> (Area Code - Telephone Number)_ <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> _ SHALL BE AS PER <br /> CURRENT M.U.T.C.D. o <br /> CALIFORNIA SUPPLERAE4 <br /> o � <br /> -.� t -u-rn <br /> c .t arn <br /> D <br /> '10 1:5q -- <br /> C <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> of erw' e-encroach uritg Highway Right-of-Way a he �1 ,� si; f <br /> approximatel feet/A%* e <br /> of by "peY€ormin the <br /> following work (des i�tion f. work) <br /> Work will commence on or about D for approximately <br /> S 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 ection and approval. <br /> DL. L7l • <br /> Signature of Applicant- Title date <br /> . MLSTn.PS\FSBSCSDL (6/00) - `,i <br />