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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br />Date 01126ji� <br />To: San Joaquin County <br />Department of Public Works <br />610 Moven, <br />Inc <br />(Applicant Name) <br />1,13D W <br />Frpmont 5T <br />(Mailing Address) <br />Voce fors, <br />ca C1520-3 <br />(City, State, Zip Code) <br />2A.161-1111 <br />FYI 3 <br />(Area Code - Telephone Number) <br />usiammiq W Dtft Mtopr <br />-Corn <br />(Email Address) <br />plans may be <br />The undersigned hereby <br />the _Rip f sic <br />of " MtQQIQ 0' <br />JOB# <br />APN <br />EXP. DA <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />110005 <br />REF # <br />CR# <br />1/29/2024 TO 3/15/2024 DRIVEWAYS: <br />D Street <br />Stockton QUAD <br />French <br />­SS/WW, R-29, Trench Cut Policy <br />Special Conditions <br />Dplies for ermission to excavate, construct and/or otherwise encroach on County HighwayRight-of-Way on <br />of iqi l approximately 15 Smile <br />1' V iv tr1 by performing the following work (description of work): <br />Work will commence on or after for approximately 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 ru es and regulations of San Joaquin County and subject to inspection and approval, <br />7 012812 3 <br />Sign u e of Applicant - Title Date <br />YIFORMSfltEMPLA1E51EN MEM PFAMR APPLiCA110Nilov RM) <br />