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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date May 3,2011 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works APN REF# <br /> CR# <br /> ATC Associates EXP.DATE � <br /> VALID <br /> (A p p I i c a n f Name) STR ET ; ,� ' 17 , / DRIVEWAYS: <br /> 1117 Lone Palm Ave.Suite 201 AREA a Q AD Get <br /> �� n ,ro� <br /> TYPE ✓ICG3 <br /> (Mailing Address) FORMS <br /> Modesto,Ca 95351 NOTES <br /> (City,State,Zip Code) <br /> (209)579-2221 <br /> (Area Code-Telephone Number) <br /> F <br /> ch(Detailed plans may be submitted) <br /> attached Figure / Plan <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 <br /> of approximately feet/mile <br /> See attached description by performing the following work(description of work): <br /> Work will commence on or about Tuesdayand Wednesday May 17&18,2011 <br /> Tuesday and Wednesday November 8&9,2011 for approximately 2 days. <br /> 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 /> Signature of Applicant-TiMay 3,2011 <br /> Date <br /> E:TUB-SVWKIMASTERPS'NCROACHMENTPERMITAPPLICATIONDDC (07/08) <br />