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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date May � "17,4 �z Z,)t/ <br /> y OFFICE USE ONLY <br /> To: San Joaquin County JOB# (I REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE -r- 2 2- z p 1 <br /> Woodbridge Firefighters Assoc VALID S^z2-Z ATO S-ZZ-zvl DRIVEWAYS: <br /> (Applicant Name) STREET t—Ad&E VAMWE <br /> AREA Co �E QUAD 1U toJ) <br /> 400 E. Augusta St. TYPE (DRkyF <br /> (Mailing Address) FORMS /U <br /> NOTES <br /> Woodbridge Ca 95258 <br /> (City,State,Zip Code) <br /> (209) 369-1945 <br /> (Area Code-Telephone Number) <br /> Sikeettch(Detailed plans may be submitted) <br /> f� J <br /> -+�1 <br /> 41 <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 oxide 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 <br /> Work will commence on or about--9 AM to 1 PM for approximately 4 h <br /> eS <br /> I, a undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> w; <br /> described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Fire Chief May 6, 2011 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKVMSTER.PSENCROACH6ENTPERNTAPPLICATK)N.DOC(01M) <br />