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APPLICATION FOR ENCROACHMENT PERMIT <br /> I�Ei C,L I V 1 <br /> PLEASE PRINT: S A N J'D A Q U 1 N <br /> p t T Y <br /> Date <br /> ' X006 APR 24 PM 1: 33 OFFICE USE ONLY <br /> _T_ <br /> QVT. O PUBLIC WORK JOB #�,1 L��t REF # <br /> To: San Joaquin Coun y CR # <br /> rrt nt of Public Works APN <br /> EXP. DATE J <br /> j1-46 VALID TO /S DRIVEWAYS: <br /> ae� STREET ETI A/Ei2 �D <br /> AREA T&&X]y 09Nf QUAD :— <br /> f tY [�✓ L-� I TYPE Z H,46 <br /> (Mailing Address) FORMStU <br /> NOTE <br /> AA 0DC-5T L CA . <br /> (City, State, Zip Code) <br /> 9- nem <br /> (Area Code - Telephone Number) <br /> Sch (Detailed plans may be submitted) <br /> CQIf �� <br /> �j 11 �[ A-' r C-i-I F <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the NNP.TO s de o T <br /> JZO" approximately 3 _ feet/mile <br /> VQr <br /> of AA A-rJ T ffF—� `i P-040 by performing the <br /> following work (description of work) : �� s <br /> �T 7 5 414 LL- PLA CF- T w("� C lel <br /> PL <br /> 430/ IL Al <br /> Work will commence on or about TU t.Lff b 62 for approximately <br /> 6 j) 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 /> inspection and approval. <br /> Signa re of Appli nt - Title Date <br /> MASTER.PS\FEESCHDL (6/00) <br />