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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2-0 <br />To: San Joaquin County <br />Department of Public Works <br />California Water Service Company <br />(Applicant Name) <br />1602 E Lafayette St <br />(Mailing Address) <br />Stockton, Ca 95205 <br />(City, State, Zip Code) <br />(209) 464-8311 <br />(Area ode - Telephone Number) <br />I cj �e+t' <br />(Email Address) <br />JOB # <br />APN <br />EXR DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />730077 REF # <br />CR # <br />TO DRIVEWAYS: <br />Various Roads - See Plans for exact locations <br />AREA <br />TYPE <br />Stockton QUAD NS <br />Trenching <br />FORMS <br />NOTES <br />rencn Uuto icy <br />Special Conditions <br />Sketch (Detailed plans may be submitted) <br />See attached <br />1906 -2- i <br />1 CC — I vol i I A <br />The undersigned hereby applies for permission to excavate, onstruct and/or otherwise encroach on County Highway Right -of -Way on <br />the V! side of r i $ pproximately ��l Li _feet/mile <br />of _ rt tic, V s _° by performing the following work ascription of work): <br />Work will commence on or after 15 1 2-&2=?for approximately I 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 />SignatuBTEMHAIESIENp20ACof A licant - Title D to <br />V:IFOPMSMRAPPLICAt10NMc("B) <br />