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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date August 19, 2010 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> City of Lodi VALID 0 ,ro /S Zoe! DRIVEWAYS.- <br /> (Applicant <br /> RIVEWAYS:(Applicant Name) STREET w `jO.Gra v <br /> AREA QUAD rtlic3 > <br /> 221 W. Pine Street TYPEe cmc <br /> (Mailing Address) FORMS �5 Lyw, <br /> NOTES <br /> Lodi, CA 95240 <br /> (City, State, Zip Code) <br /> (209) 333-6800 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attached. <br /> I <br /> I <br /> I <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the west side of_ Lower Sacramento Rd approximately 0 feet/mile <br /> of Carolina Street Lodi , by performing the following work(description of work): <br /> Replace existing storm drain and construct new storm drain, construct new sidewalk, and construct driveway for <br /> raw water pump station. <br /> Work will commence on or about_ January 1 for approximately 300 _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 /> Signattde of Applic t-Title Date <br /> E'�PUBSVWNV.IAS?EPPS'ENCROACHMENI PERMITAPPLICATION DOC (01108; <br />