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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> .DEC - 9 2006 <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # ro REF # <br /> Department of Public Works APN CR00, # <br /> EXP. DATE 3 <br /> VALID• a TO DRIVEWAYS:. <br /> (Applicant Name) STREET <br /> l•KJ �5� �� AREA TRevc►+CSP QUAD <br /> _ . TYPE -EMlL-NoLE <br /> (Mailing Address) FORMS _-fno1WWL <br /> NOTE <br /> !i" <br /> (City, State, .Zip Code) <br /> —t eT <br /> (Area Code - Telephone Number) 0 <br /> Sketch (Detailed plans may be submitted) a' = <br /> TRAFFIC CONTROL A h1-- f <br /> �C "r Al+A�� SKE A SHALL BE AS PER o <br /> -_� _ CURRENT M.U.T.C.D30 _ <br /> CALIFORNIA 5UPPL�MWT <br /> o#1 0221 Z` °I 1 - ` o¢oE <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> of erwise-encroach on County­Highway. Right-of-Way--on-the �.( side.:of <br /> �' approximately feet/am a � <br /> of V. by "per€o m rig the <br /> following work (description of: ork) : <br /> 61 AS <br /> Work w'11 commence on or about OO 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 /> ins on and approval. <br /> DEC - 9 2006 <br /> Signature of Appli ant Title Date <br /> KL9THR.PS\MWS®L (6/00) <br /> i <br /> i <br />