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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date January UtS OFFICE USE ONLY <br /> To: San Joaquin County JOB# � ��117 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> California Water Service Company VALID 2--q-26VI-To t,—/f--2->j5—DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD x <br /> 1720 North 1st Street TYPE Q <br /> (Mailing Address) FORMS S�/W 122q T YeC(•--�l�G�` <br /> NOTES <br /> San Jose, CA 95112 <br /> (City,State,Zip Code) <br /> 408-367-8321 <br /> (Area Code.Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Plans and calculations attached. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County HighRight-of Way on <br /> the west side of Wilcox Road approximately 100 (feet/ilnile north <br /> of Wilcox Road by performing the following work( caption of work): <br /> in'��lma 60 inear ee o "R�P��ainTafe a connec)n fo t e exts tngmain wt a manhole <br /> Work will commence on or about 2/09/2015 for approximately 5 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 /> _. <br /> Associate"Engineer ` Januarv-08:2d1S" <br /> Signature of Applicant•Title Date <br /> l John Puccinelli <br /> tdiCENTRALSERVICESVCLERICALYPUB-SV.tMh'tI.ASTEP,PSVENCROACHLIENTPE.q,NRAPR"TIMIDOC (013) <br />