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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date March 26,2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# /1"S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE // h <br /> ATC Associates VALID /7 2 TO // J2. DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAQU D /I! <br /> 1117 Lone Palm Ave.Suite 201 TYPE 64#01 A!elZeZ <br /> (Mailing Address) FORMS <br /> NOTES <br /> Modesto,Ca 95351 /12 III B / •el/ Lf/� $, <br /> (City,State,Zip Code) <br /> (209)579-2221 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See 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 approximately feet/mile <br /> of by performing the following work(description of work): <br /> See attached description <br /> Work will commence on or about Tuesday and Wednesday April 17 and 18,2012 for approximately 2 days. <br /> Tuesday and Wednesday November 8&9,2012 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 /> March 26,2012 <br /> Sigp-Sture of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTEUSIENCROACHMENTPERWTAPPUCATION.DOC(01/08) <br />