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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT' <br /> OFFICE USE ONLY <br /> Date .-/!> -69 <br /> JOB# REF# <br /> To: San Joaquin County + <br /> Department of Public Works APN CR# <br /> EXP.DATE '09 DRIVEWAYS: <br /> IIF VALID •D TO •O9 <br /> (Ap ant name) STREET QUAD 169S , <br /> AREA _ <br /> TYPE <br /> (Failing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> 2d� <br /> -(Area Code-Tel Number) <br /> Sketch(Detailed plans may be submitted) <br /> 997 Jam, 6/ tib <br /> A,PA 157 V V /40 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa jRight9-'d�� <br /> the tom• side of �Si� ��- �� approximate) sr46 &2m `-�- <br /> ofby performing the following work(description of work): <br /> -AMW 444 <br /> Work will commence on or about S&r---0! for ap roximately ? days. <br /> I,the undersigned,certify that I am the owner of the respective property, or am qualifie�nty' <br /> trepresent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin Co and subject to inspection and approval, <br /> Signa ure o e <. _ Date <br /> Y+FORMS 6 TEMPLATMENCROACHMW PERMIT APPUCATIONAm 10&081 <br />