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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 730Q S� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ( -I <br /> PG&E VALID - TO - ! _ DRIVEWAYS: <br /> (Applicant Name) STREET f t rl <br /> 4040 WEST LN AREA QUAD _ k <br /> TYPE <br /> (Mailing Address) FORMS 1 <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 /> The undersigned hereby applies for permission to excavate, construct and!or otherwise encroach on County Highway Right-of-Way on <br /> the $cuth side of Florida Ave approximately 133' feet/mile west <br /> of W Myran Ave , Stockton by performing the following work(description of work): <br /> Excavate 1 4'x4'bellhole for gas service replacement <br /> Work will commence on or about ?-M('57,3) for approximately 60 days. <br /> I,the uersigned,certify that I the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> V describe}!above in ac,,=ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> f <br /> Sig ture of Applicant-Title Date <br /> E;IPU&SV.WKWJISiER.PSiENCROAACHMENTPERKTAPPUOAIlON.000(010) <br />