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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> NOV 2 1 2006 OFFICE USE ONLY <br /> Date <br /> JOB # X30 SL- REF # <br /> To: San Joaquin County CR # <br /> Department of Public Works APN <br /> _01 EXP. DATE �a 06 <br /> VALID �� TO G DRIVEWAYS:. <br /> (APP iCaat Name) STREET !4OWLAIo-+i. o fit W EE* <br /> * <br /> AREA QUAD CG <br /> TYPE -Fw1 L_ blo(a K <br /> (Mailing Address) FORMS <br /> NOTE <br /> (City, Sta e, .Zip Code) <br /> �Zo97 <br /> T (Area Code - Telephone Number) . <br /> Sketch. (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> Y � <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned he applies for permission to.excavate, construct and./or <br /> otherwise-encroach on County Highway Right-of-Way-on-the <br /> approximately feet/mile <br /> y ' er€ormin <br /> Xthe <br /> of <br /> following -work descriptio of work) : <br /> 0 <br /> Work ill commence on or about 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 /> in cti and approval. <br /> VNoM a»fn�! -� 2 1 2006 <br /> signature of AppliC t Title 0 :0I baa LZ AON 9001 Date <br /> MSTSR.YS\FBSS®L (6/00) <br /> (l 3 A 13 0 3'•s <br />