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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date September 25, 2010 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR <br /> EXP.DATEf IVN,., <br /> Woodbridge Fire Fighters Association VALID cl-. -2,ap DRIVEWAYS: <br /> (Applicant Name) STREET - �N14e.%I x <br /> AREA QUAD N <br /> 400 E. Augusta St. TYPE/ <br /> (Mailing Address) FORMS <br /> Woodbridge, CA. 95258 NOTES <br /> (City,State, Zip Code) <br /> 209-369-1945 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> IT.zS t-0 p <br /> x <br /> Mokelumne St. Lower Sacramento Rd. <br /> G� 3 <br /> Stop I Woodbridge, CA. North <br /> i Location of Members <br /> t <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the i ntersecti Olde of Mokel umne/Lower Sacramento approximately 50 feet/mile <br /> of , by performing the following work(description of work): <br /> Fill the Boot fundraiser for the Firefighter Burn Institute in conjunction with <br /> Nation Eire Prevention Week—recocinition <br /> Work will commence on or about 4 <br /> 1 0 0 0 for approximately 4 hnijr- -deps— <br /> I,the undersigned, certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> ( described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Vice President July 15, 2010 <br /> Signature of Applicant-Title Date <br /> �VPUMV.WKIMASTER MENCROACNAENT PERMIT APPLICATION DOC (Gin) <br />