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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6/16r 7-of If OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11,9006- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE o <br /> Central Valley Telecom VALID / A Tb a?//O/;L DRIVEWAYS: <br /> (Applicant Name) STREET A ears ,9D• <br /> AREA QUAD <br /> 855 M St. Ste. 1120 TYPE 'eZROZ65 o& <br /> (Mailing Address) FORMS 1✓iJ 9 <br /> NOTES <br /> Fresno, CA 93721 <br /> (City,State,Zip Code) <br /> 559-442-6010 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The un rsigned hereby applies for gormission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the iff2rsidmf ( i0lz)1l5 19ps- approximately feet/mile <br /> of by performing the following work(description of work): <br /> See plans for details,various streets in County right of way <br /> Work will commence on or about 1/3/2012 for approximately 30 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 /> ho i <br /> f-Ap ' nt- i Is Nte <br /> E:IPUB&SV.V AS PSIENC OACHMENTPERMR APPLICATION,DOC(010) <br />