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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3/2/2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# f/per REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE to 'to 12 <br /> Woodbridge Firefighters Association VALID Za;z To )Z DRIVEWAYS: <br /> (Applicant Name) STREET e14ei_6z�,_&P /- 3",fotzoz) 9D. <br /> AREA �J j$,E'/I•Y� QUAD / x) <br /> 400 East Augusta Street TYPE �aooT Turd, <br /> (Mailing Address) FORMS -� <br /> NOTES <br /> Woodbridge, CA 95258 <br /> (City,State,Zip Code) <br /> 209 369 1945 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> rYl© l <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 aside of Mokel umne/Lower Sacramentn approximately 50 feet/mile <br /> of , by performing the following work(description of work): <br /> Fill the Boot fundraiser for the Firefighter Burn Institute in conjunction with <br /> National Fire Prevention Week recognition <br /> n 14y 6, 2,0, <br /> Work will commence on or about 9:00 -4:00 p.m. for approximately f `7 fjeys. <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 /> 3/2/2012 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WMMASTER.PSIENCROACHMENT PERMTAPPLICATION.DOC (01108) <br />