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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date October 27, 2010 OFFICE USE ONLY <br /> To: San Joaquin County JOB# _//A065 REF# <br /> Department of Public Works APN CR# <br /> �ww!!'� O <br /> ATC Associates — EXP.DATE <br /> A ICE:�nIIG� VALID O TO ,r- o DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAyAl QUAD /ISS <br /> 1117 Lone Palm Ave. Suite 201 TYPE <br /> (Mailing Address) FORMS a <br /> Modesto, Ca 95351 NOTES <br /> (City,State,Zip Code) <br /> (209) 579-2221 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See attached Figure / Plan <br /> �D,Q,e 114!/,eS tyt&y �71AO �4 rY <br /> # ,Gtr9XE S► is o✓.s.ays Ore,e .Vdr 0_1u�/.14 VP-111,eAyS <br /> -,66 IV07e dN T,eA✓—'.a:« Gonl7'40Z )"All <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of Wilson way and Sanguinetti Lane approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about NoyF�mhPr R. 2nl n for approximately 2 days. <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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> October 27, 2010 <br /> Signature of Applicant-Title Date <br /> E 1PUB-SVWKNAASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01)08) <br />