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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 8/25/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 0 0 Q_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ( Q - 3(-(1- <br /> PG&E VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET _ 5JQ4 �f�J �hkl�R� <br /> 4040 WEST LN AREA LO QUAD IV <br /> TYPE <br /> (Mailing Address) FORMS c (/✓ Z <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 209-942-1421 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <br /> PM 31096523 <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 HWY 99 FRONTAGE RD WEST approximately feet/mile sot ITH <br /> of mnNFRY Rn , ACAMPn , by performing the following work(description of work): <br /> EXCAVATE (2)4'x4' RFI I HCII ES TRENCH 195' AND BORE 60'To RFI O(-ATF CAS mFTFR Fgom INSInF THF <br /> GARAGE AT 18881 H1/1Y 99 FROI TAGS RD WEST, ACAMPn <br /> Work will commence on or about 10/1/2014 for approximately 60 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 /> 8/25/2014 <br /> Signature of Applicant-Title Date <br /> E:TUB-SV.WKWASTER.P&ENCROACHMENT PERMIT APPLICATION.DOC (oiroe) <br />