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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> USE ONLY <br /> ate 06/25/2014 <br /> To: San Joaquin County JOB# ( l 000 S REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE: g- t S - <br /> VALID 7-�-« TO �_ ( S- 11 <br /> DRIVEWAYS: <br /> Amanda Kahn DD <br /> (Applicant Name) STREET O I� <br /> AREA d QUAD <br /> 3911 West Capitol Avenue TYPE <br /> (Mailing Address) FORMS S Sl W(- A Z % <br /> NOTES <br /> West Sacramento,CA 95691 <br /> (City, State, Zip Code) <br /> (916)371-1690 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attached plans. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the west side of Sexton Road _approximately 0.5 miles feet/mile north <br /> of intersection of East River Road Escalon,California , by performing the following work(description of work): <br /> See attached work description and figure. <br /> Work will commence on or about pending permit approval for approximately 1 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 /> �,,L�Kz��/, ,C-i:LT 0b 25 2O N <br /> Signature of Applicant-Title Date <br /> M.XCENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />