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APPLICATION FOR ENCROACHMENT PERMIT <br />PL SE PRINT; <br />Date /Z-S-Zl <br />To: San Joaquin County <br />Depoof Public Works <br />(Applicant Name) <br />(Malling Add ) <br />649- L1124c/ <br />(City, State, Zip Code) <br />-2.ai Z-42-trco 3 <br />(Area Code - Telephone Number) <br />(Email Address) <br />JOBB <br />730052 REF# <br />APN <br />_ <br />- -� CR # <br />EXP. DATE <br />VALID <br />_- <br />12% 0/2021 T6 --F7577027— _ <br />STREET <br />Bern Rd. <br />AREA <br />Stockton QUAD <br />TYPE <br />Pole Replacement <br />FORMS <br />SS/WVV <br />NOTES <br />Special Conditions <br />DRIVEWAYS: <br />Sketch (Detailed plans may be submitted) <br />/l 4` 1t <br />V <br />O <br />The undersigned hereby applies r permission n4excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the (' side of r F 1 approximately ��� feet/mile �11A;1 <br />of ono e. e I , S 7 — . ' by performing the following work (description of work): <br />d0 <br />Ode <br />�s� r: csos <br />Work will commence on or after - - Z for approximately days. <br />I, the undersigned, certify that I am the owner of th rty, or am qualified to represent the owner and agree to do the <br />work described above in accorda Mes and regulations of oaquin County and subject to inspection and approval. <br />Signature of Date <br />